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BLOOD -PRESSURE 
PRIMER 

THE 

SPHYGMOMANOMETER 

AND  ITS  PRACTICAL 
APPLICATION 

BY 
FRANCIS  ASHLEY  FAUGHT,  M.D. 

LATE  DIRECTOR   OF   THE  LABORATORY   OF   CLINICAL   MEDICINE,    MEDICO- 

CHIRURGICAL    COLLEGE   AND    HOSPITAL.       INSTRUCTOR    IN    MEDICINE, 

MEDICO-CHIRURGICAL     COLLEGE.       AUTHOR     OF     ESSENTIALS     OF 

LABORATORY    DIAGNOSIS.    BLOOD    PRESSURE    FROM    A 

PRACTICAL     STANDPOINT,    ETC.,    ETC. 


Containing  One  Full-page  Plate  and  Numerous 
Explanatory  Diagrams  in   the   Text 


COPYRIGHT,        1914 
B  Y 

FRANCIS  Ashley  Faught 


PUBLISHED       BY 

G.     P.     PILLING    &    SON     CO. 

PHILADELPHIA 
1914 


Pilling-Faught  Pocket  Sphygmomanometer  in  Use. 


C  O  N  T  E  N  1  S 


CHAPTER  I. 

i'A(;k 
The  Value  of  the  Sphygmomanometer         .  3 

The  Diastolic  Test. 

CHAPTER  H. 
The  Circulation  15 

CHAPTER  111. 
The  Sphygmomanometer         ....        21 

CHAPTER  IV. 
Normal  Blood-Pressure  and  its  Variations         53 

CHAPTER  V. 
Practical  Application  of  Clinical  Data     .         65 

CHAPTER  VI. 
Pregnancy,  Toxemia  and  Eclampsia     .         .        91 

CHAPTER  VII. 
Blood-Pressure  in  Surgery  and  Anesthesia        95 
Dental  Anesthesia. 

CPIAPTER  VIII. 
Therapeutics  Indicated  by  Blood-Pressure 

Changes Ill 

CHAPTER  IX. 
Blood-Pressure  in  Life  Insurance         .         .       115 


CHAPTER  I. 


THE  VALUE  OF  THE  SPHYGMOMANOMETER, 

The  Importance  of  the  Blood-Pressure  Test    .  4 

In  General  Diagnosis          .         .         .         .  5 

In  Insurance  Examinations          .         .         .  6 

Importance  of  Diastolic  Reading    ....  6 

Accuracy  of  the  Auscultatory  Method         .  7 

The  Pulse  Pressure     .....  8 

Normal  Relations  in  Complete  Blood-Pressure  Tests  9 

Graphic  Formulas  for :         .         .         .         .  9 
Estimation  of  Heart  Work          .         .         .10 

Estimation  of  Velocity         ....  10 

In  Arterial  Disease     .         .         .         .         .  11 

In  Heart  Disease 12 

Example  of  Case         .         .         .         .         .  12 

Infectious  Diseases      .....  13 


CHAPTER  I. 

THE   VALUE  OF  THE  SPHYGMOMANOMETER  AND 
THE  IMPORTANCE  OF  THE  BLOOD- 
PRESSURE  TEST. 

"The  value  of  the  blood-pressure  test  is  acknowl- 
edged by  every  up-to-date  physician.  Like  the 
clinical  thermometer,  the  stethoscope  and  other 
instruments  of  precision,  the  sphygmomanometer 
is  an  aid  to  accuracy  in  diagnosis,  and  any  instru- 
ment that  will  enable  the  physician  or  surgeon  to 
do  better  work  is  not  to  be  set  aside  or  passed  by 
without  careful  investigation."  (J.  F.  Prendergast, 
Chicago  Medical  Record,  March,  1913.) 

The  best  single  guide  to  the  practical  value  of 
a  new  method  is  to  determine  whether  it  is  receiv- 
ing increasing  endorsement  from  qualified  authori- 
ties. At  the  present  time  all  well-equipped  hospi- 
tals have  sphygmomanometers  in  daily  use  in  the 
wards.  It  is  seen  in  Children's  Wards  as  a  guide 
to  prognosis  and  treatment ;  in  Obstetrical  Wards 
in  diagnosis  and  treatment  of  toxemias. 

The  oculist  and  aurist  are  finding  blood-pressure 
measurement  of  increasing  value,  and  tuberculosis 
sanatoria  are  modifying  their  prognosis  and  treat- 
ment according  to  the  indications  of  this  sign. 

J.  B.  McAllister,  in  "The  Medical  Council"  for 
July,    1912,   states   that   the   Medical    Director    of    a 


Importance  of  Test. 


large  insurance  company  published  statistics  which 
show  that  in  1247  risks  of  all  ages  in  which  there 
was  a  blood-pressure  of  150  mm.  Hg.  or  over,  the 
mortality  was  2^  times  greater  than  the  general 
average  mortality  of  the  company  covering  the 
same  period. 

Richard  C.  Cabot  says:  "If  I  were  allowed  to 
have  only  two  instruments  of  precision  for  my  aid 
in  physical  diagnosis,  they  would  be  the  stetho- 
scope and  sphygmomanometer.  I  have  been  saved 
from  wrong  diagnosis  and  put  on  the  track  of  right 
ones  more  often  by  this  machine  than  anything 
else  I  know  of  except  the  stethoscope.  I  regard  this 
measurement  of  the  blood-pressure  as  the  most 
important  of  all  the  resources  that  have  been  added 
to  our  armamentarium  as  physicians  in  the  last  15 
years.  I  could  talk  all  afternoon  on  the  subject  of 
blood-pressure,  but  I  will  confine  myself  to  saying 
that  it  puts  me  right  most  often  in  relation  to  car- 
diac and  renal  diseases.  Patients,  the  examination 
of  whose  hearts  did  not  show  anything  certainly 
characteristic  of  disease,  have  often  been  shown  to 
me  to  be  diseased,  or  proved  later  to  be  diseased, 
by  the  high  blood-pressure  registered  by  the  ma- 
chine, pressure  which  my  fingers  are  not  always 
able  to  detect.  In  feeling  the  pulse  I  no  longer 
trust  my  fingers  to  be  sure  of  a  high  tension  pulse; 
I  used  to,  but  I  have  convinced  myself  that  I  can- 
not do  it.  On  the  other  side  there  are  many  irregu- 
lar hearts,  which  you  finally  conclude  to  be  merely 
functional  in  origin,  having  no  immediate  signifi- 
cance; because  the  blood-pressure  is  normal.  An 
irregular  heart  plus  a  high  blood-pressure  is  serious. 


Importance  of  Test. 


The  very  same  irregular  heart,  with  low  pressure, 
may  be  of  no  great  significance. 

"Then  call  your  attention  to  the  early  diagnosis 
of  kidney  lesions.  I  see  a  good  many  cases  of  renal 
disease  entirely  free  from  albumin  or  from  casts, 
but  with  high  blood-pressure,  which  are  shown, 
post-mortem,  to  be  renal  disease.  These  cases  could 
not  have  been  suspected  to  be  renal  diseases  ex- 
cept by  blood-pressure.  In  other  words,  I  regard 
the  blood-pressure  measurement  as  of  more  im- 
portance than  the  examination  of  the  urine  in 
chronic  kidney  trouble.  Examination  of  a  specimen 
has  again  and  again  led  me  astray;  the  measure- 
ment of  blood-pressure  almost  never." 

Physicians  who  can  practice  successfully  without 
materials  for  a  urinalysis  or  without  a  blood-pressure 
instrument  will  find  it  difficult  to  hold  insurance 
appointments ;  furthermore,  patients  are  learning 
that  an  examiner  who  is  preferred  by  an  old  insur- 
ance company  is  the  safest  man  to  trust  as  a  physi- 
cian. 

A  hundred  examiners  could  give  us  a  reliable 
blood-pressure  reading  where  only  one  could  detect 
cardiac  hypertrophy  or  an  accentuated  aortic  second 
or  a  minute  trace  of  albumin  in  chronic  interstitial 
nephritis. 

The  foregoing  has  all  been  said  of  the  simple 
estimation  of  the  systolic  blood-pressure,  as  made 
by  the  modern  sphygmomanometer,  of  which  the 
Faught  instruments  are  typical.  It  must  not  be 
forgotten,  however,  that  recent  developments  in  the 
study  of  blood-pressure  have  emphasized  the  grow- 
ing  importance    of    the    diastolic    pressure.      In   this 


The  Diastolic  Test. 


connection  I  quote  again  from  the  article  of  Dr. 
Prendergast  above  referred  to,  in  which  he  says : 
"Some  of  our  cHnicians  place  little  value  on  dias- 
tolic pressure  for  the  simple  reason  that  they  can- 
not interpret  its  findings.  This  is  a  great  mistake, 
as  the  systolic  pressure  is  only  one  side  of  the 
picture,  and  we  cannot  explain  the  pulse  pressure 
or  judge  of  the  systolic  output  or  the  work  the 
heart  is  doing  without  knowing  the  diastolic  pres- 
sure. Now  I  contend  that  it  is  of  great  importance 
to  know  whether  under  certain  conditions  the  pulse 
pressure,  if  20,  40,  60  or  even  100.  In  the  first 
case  it  would  mean  a  rather  feeble  drive  to.  the 
heart,  with  a  small  systolic  output.  In  the  latter 
the  heart  is  working  too  hard  in  overcoming  periph- 
eral resistance,  or  loss  of  elasticity  in  the  vessel 
wall,  and  is  calling  on  its  reserve  capacity;  as  long 
as  it  is  compensated  we  have  a  good  case,  but  once 
our  reserve  capacity  is  overcome  and  decompensa- 
tion sets  in,  look  out  for  trouble.  The  narrow  pulse 
pressure  is  found  in  wasting  diseases,  like  tuber- 
culosis, in  shock,  after  profuse  hemorrhage,  in  chlo- 
rosis, etc.,  and  always  accompanies  a  failing  heart." 

Diastolic  Test. 

Until  the  practical  demonstration  of  the  accuracy 
of  the  Auscultatory  or  Auditory  method  of  reading 
blood-pressure,  little  valuable  work  was  recorded 
in  connection  with  this  test,  for  the  reason  that  so 
much  difficulty  was  experienced  in  making  this 
part  of  the  test,  that  few  routinely  employed  it, 
and  those  who  made  this  effort  were  not  repaid 
for  their  trouble,   as  the  figures    obtained    were    so 


The  Diastolic  Test. 


uncertain  and  unreliable  that  no  dependence  could 
be  placed  on  them. 

The  studies  of  Warficld  and  others  have  shown 
the  accuracy  of  this  method,  which  can  be  relied 
upon  to  give  an  accurate  reading  under  practically 
all  circumstances,  irrespective  of  the  age  of  the 
patient,  the  size  of  the  vessel,  or  the  size  of  the  arm  to 
which  the  cuff  is  attached. 

In'  order  to  analyze  the  results  of  a  complete  blood- 
pressure  observation,  it  is  essential  to  review  the  fac- 
tors controlling  blood-pressure.  From  the  clinical 
standpoint  at  least,  we  may  consider  the  blood-pressure 
depending  mainly  upon  the  contractile  powers  of  the 
heart,  which  pumps  the  blood  forward,  on  the  one 
hand,  and  the  calibre  of  the  blood-vessel  walls,  which 
offer  peripheral  resistance  to  its  flow,  on  the  other. 
And  also  that  peripheral  resistance  itself  depends 
largely  on  the  tonicity  of  the  walls  of  the  blood-vessels 
which  comprise  the  general  capillary  system.  Patho- 
logically, we  must  recognize  that  changes  in  blood- 
pressure  are  largely  due  to  departures  from  the  normal 
force  of  the  heart  and  to  alterations  in  the  elasticity 
and  tonicity  of  the  general  arterial  tree.  It  will  thus  be 
seen  that  the  systolic  pressure  will  approximate  closely 
the  actual  pressure  developed  by  the  heart  within  the 
heart  itself  at  the  moment  of  systole,  while  the  mini- 
mal or  diastolic  pressure  wall  be  the  measurement 
of  the  peripheral  resistance,  w^hich  is  able  to  maintain 
to  a  varying  degree  the  arterial  pressure,  while  the 
heart  is  dilating,  plus  the  factor  of  elasticity,  wdiich  also 
aids  in  maintaining  the  continued  pressure  in  the  vessel 
during  diastole. 

In   the  pulse  pressure,   then,   we   must     have     the 


The  Pulse  Pressure, 


measurement  of  the  amount  of  force  exerted  by  the 
heart  in  maintaining  blood-pressure  over  and  above 
that  normally  maintained  by  peripheral  resistance,  i. 
e.,  the  pulse-pressure  gives  a  figure  which  roughly 
measures  the  pumping  capacity  of  the  heart.  These 
facts  show  clearly  the  importance  of  always  making 
a  diastolic  reading,  so  that  the  pulse  pressure  may  be 
computed. 

Gibson,  due  to  his  ingenuity  and  experience,  has  de- 
vised formulae  whereby  we  are  able  to  more  or  less 
carefully  estimate  not  only  the  capacity  of  the  heart 
for  work,  but  also,  in  a  rough  way,  its  output. 

Gibson  has  demonstrated  that  there  exist  certain 
definite  relations  between  these  several  factors  and  has 
combined  them  into  a  working  formula.  Briefly,  these 
propositions  are  as  follows: 

Under  normal  conditions  there  is  a  definite  relation- 
ship between  systolic  and  diastolic  pressure  and  also  a 
relation  between  systolic  and  pulse-pressure.  The  re- 
lation of  the  diastolic  pressure  to  the  systolic  pressure 
obtained  by  auscultation  is  about  as  two  is  to  three  and 
that  of  pulse-pressure  to  the  systolic  pressure  as  one 
is  to  three.  For  example,  if  the  systolic  pressure  is 
140,  the  normal  diastolic  will  be  approximately  95, 
while  the  pulse-pressure  should  approximate  45  or  50. 

If  we  bear  in  mind  the  fundamental  fact  that  all 
blood-pressure  readings  vary  normally  within  certain 
well-known  limits,  it  will  readily  be  seen  that  these 
relations  are  at  best  only  approximate,  which,  how- 
ever, does  not  materially  detract  from  their  clinical 
value.  Actually  employed,  they  have  been  found  to  be 
most  valuable  guides  in  separating  the  normal  from  the 
pathological  and  in  estimating  the  degree  of  over-load 
in  cardio-renal  cases. 


Gibson's  Formula. 


Following  tlie  same  reasoning,  if  the  pulse-pressure 
roughly  estimates  the  systolic  output,  it  follows  that 
this  is  also  an  important  factor  in  the  velocity  of  the 
blood-stream,  which  for  i)hysical  reasons  must  bear  a 
definite  relation  to  the  volume  output  of  the  heart  and 
to  the  caliber  of  the  conduits — the  arteries — so  that,  if 
other  factors  remain  the  same,  it  is  not  a  difficult  mat- 
ter to  estimate  both  the  velocity  and  also  the  work  of 
the  heart  while  operating  under  either  normal  or  ab- 
normal conditions. 

The  above  propositions  can,  according  to  Gibson,  be 
arranged  graphically  as  follows  : 

For  example,  take  a  case  presenting  these  figures : 
S.  P.  130,  D.  P.  85,  P.  P.  45,  P.  R.  70;  then— 
P.  P.  (45)   X  P.  R.  (70)  =  Velocity  (3100),  and 
S.  P.  (130)  X  P.  R.  (70)  =  Work  (9100). 
We  may  carry  our  calculations   further  and  state 
that  the  velocity  and  the  work,  as  estimated  by  the 
above   formula,   also  bear  a   definite  normal   relation 
which  is  dependent  entirely  upon  the  normal  relation 
of  pulse-pressure  to  systolic  pressure  (which  can  only 
be  determined  by  measuring  the  diastolic  pressure). 
This  velocity-work  relation  is  as  one  is  to  three,  and 
is  not  dependent  upon  the  pulse  rate.     For  as  long  as 
the  relation  of  systolic  to  diastolic  pressures  remain 
normal  (they  may  of  course  be  different  in  every  case, 
without  changing  their  normal  relation),  the  velocity- 
work  ratio  will  be  normal,  no  matter  what  the  pulse 
rate.     If  we  have  a  more  rapid  pulse,  with  unchanged 
pressure,  we  undoubtedly  increase  the  total  expendi- 
ture of  heart  energy,  both  for  velocity  and  work;  on 
the  other  hand,  it  is  possible  to  conceive  of  a  decreased 
pulse    rate    with   a     rising    general    pressure,     w-hich 


10  Gibson's  Formula. 


would  not  only  allow  the  velocity-work  ratio  to  remain 
unchanged,  but  which  need  not  necessarily  add  ma- 
terially to  the  work  of  the  heart.  As  a  matter  of  fact, 
this  is  precisely  what  does  occur  within  certain  limits 
under  normal  conditions.  To  show  this,  it  is  only 
necessary  to  note  the  effect  of  change  in  posture  upon 
blood-pressure  and  pulse  rate,  as  discussed  on  page  00. 

The  normal  arterial  tree  will  withstand  a  continual 
variation  in  pressure  of  from  35  to  50  mm.  without 
undergoing  pathologic  change.  Under  those  condi- 
tions in  which  we  have  a  pulse-pressure  of  more  than 
this,  it  is  evident  that  the  blood-vessels  are  required 
to  withstand  undue  stress ;  and  so  if  we  here  subtract 
the  normal  pulse-pressure  from  the  pathologic,  we 
have  relatively  the  measurement  of  the  increased  work- 
ing of  the  heart.  Now  if  this  difference  is  multiplied 
in  turn  by  the  pulse  rate  per  minute,  then  by  60  and  by 
24,  it  is  very  easy  to  see  the  relatively  tremendous  ex- 
cess of  work  and  energy  required  of  the  heart  in  every 
24  hours  in  order  to  maintain  circulation  and  nourish 
the  tissues.  This  w^ould  seem  to  be  the  true  explana- 
tion of  heart  hypertrophy,  arterial  change  and  ultimate 
cardiac  dilatation  with  failing  circulation. 

Lauder  Brunton  says  "The  diastolic  pressure  is  a 
factor  of  great  importance,  because  by  its  amount 
and  by  the  dift'erence  between  it  and  the  systolic  pres- 
sure we  obtain  valuable  data  in  regard  to  the  strength 
of  the  heart  and  the  condition  of  the  arterioles." 

V.  Pachon  w^as  among  the  first  to  express  the  belief 
that  the  normal  systolic  pressure  was  not  only  of  un- 
certain value  in  the  study  of  many  pathologic  cases, 
but  that  its  variation  within  wide  limits  and  at  short 
intervals    for  any   individual,   even   slight  physiologic 


TiiK  Diastolic  Pkkssuuk 


causes,  might  be  actually  misleading,  as  under  the  fol- 
lowing conditions:  In  decomi)ensaled  cardio-renal 
cases  where  the  maximal  pressure  may  be  normal,  it 
is  only  by  determining  the  abnormal  elevation  of  the 
diastolic  pressure  and  consequent  reduction  in  ])ulse- 
pressure  that  we  are  able  to  clinically  confirm  the  cir- 
culatory fault. 

The  minimuni  pressure  represents  the  true  constant 
load  borne  by  the  arterial  tree  and  the  resistance  which 
the  heart  is  obliged  to  overcome  before  its  contents 
can  be  expelled.  Both  data  of  fundamental  importance 
from  the  clinical  pathologic  standpoint.  It  has  been 
found  also  that  the  diastolic  pressure  is  a  far  more 
constant  factor  in  normal  individuals  than  the  systolic, 
that  it  is  practically  the  same  for  all  parts  of  the  arterial 
tree,  while  the  maximal  pressure  drops  progressively 
from  aorta  to  periphery. 

W.  R.  Sheldon,  Medical  Record,  December  31st, 
1910,  adds  the  following  to  our  already  rapidly  in- 
creasing information : 

The  lessened  elasticity  of  the  arteries  which  is 
found  in  many  conditions  contributes  to  an  abnormal 
relation  between  the  diastolic  and  systolic  pressure,  so 
that  in  long-continued  high  blood-pressure,  due  to  les- 
sened elasticity  in  the  artery,  there  is  a  failure  of  the 
diastolic  pressure  to  maintain  its  normal  relation.  The 
pulse-pressure  is  increased  and  we  can,  by  the  formula 
already  described,  estimate  the  amount  of  extra  work 
which  is  demanded  by  the  high  pressure  incident  to 
arterial  rigidity.  From  these  we  can  draw  the  follow- 
ing corollary,  which  is,  that  increased  strain  on  the 
heart  is  to  a  large  degree  measured  by  the  amount  of 
diastolic  failure,  i.  e.,  the  larger  the  pulse-pressure  in 


12  The  Diastolic  Pressure. 

relation  to  the  diastolic  pressure,  the  greater  will  be 
the  cardiac  strain,  which  finally  fails  to  respond  to 
the  increased  demands  and  enters  into  a  condition  of 
decompensation.  So  that  we  may  look  for  signs  of 
poor  circulation  when  there  is  a  high  systolic  pressure 
and  a  diastolic  pressure  that  is  relatively  low;  and 
conversely,  if  measures  directed  toward  removing  the 
cause  of  this  abnormal  relation  are  successful,  we  may 
measure  the  amount  of  improvement  by  the  elevation 
of  diastolic  pressure  and  consequent  reduction  of 
pulse-pressure,  as  is  well  shown  in  the  case  above  de- 
scribed. 

These  two  formulas  have  been  discussed  at  some 
length  because  of  their  fundamental  importance  and 
wide  applicability.  By  means  of  these,  it  is  a  simple 
matter  to  compute  the  excessive  work  required  of  the 
normal  heart  under  varying  conditions  of  strain  and 
load,  and  also  in  those  pathologic  conditions  of  the 
circulation  accompanied  by  changes  in  the  heart,  blood- 
vessels and  kidneys.  Anyone  who  appreciates  the  value 
of  the  blood-pressure  test  will  find  these  studies  of 
great  assistance  in  diagnosis,  prognosis  and  treatment. 

The  following  case  from  actual  practice  shows  the 
method  of  its  employment  and  the  information  de- 
rived : 

Case  of  Chronic  Myocarditis  and  Arteriosclerosis. 

Before  treatment—S.  P.  210,  D.  P.  100,  P.  P.  110, 
P.  R.  104. 

S.  P.  (210)  X  P.  R.  (104)=\ 

Work  (21840)  _       . 

P.  P.  (110)  X  P.  R.  (104)  —'  ~  ^^^^^  ^  ^°  ^• 


Velocity  (11440)  ) 


Effect  of  Treatment.  13 

After  two  weeks'  treatment— S.  P.  195,  D.  P.  140, 
P.  P.  55,  P.  R.  84. 
S.  P.  (195)  X  P.  R.  (84)  =\ 

Work  (14580)  __ 

P.  P.  (55)   X  P.  R.  (84)  =   -  ""^^'^  ^  ^°  ^• 

Velocity  (4620)  ) 

Here,  under  proper  methods  of  treatment,  the 
work-velocity  was  greatly  benefited,  the  actual  work 
reduced  one-third,  so  that  while  the  heart  was  at  first 
only  able  to  maintain  the  needs  of  the  case  under 
serious  strain,  and  accompanied  by  evident  signs  of 
cardiac  distress.  After  two  weeks  the  danger  of  acute 
failure  of  the  circulation  was  overcome  and  the  whole 
complexion  of  the  case  altered  for  the  better. 

In  pneumonia  and  most  infectious  diseases  a 
falling  blood-pressure  with  a  narrowing  pulse-pres- 
sure means  great  danger.  A  wide  pulse-pressure 
is  found  in  arteriosclerosis,  with  loss  of  elasticity 
in  the  blood-pressure  and  with  increased  peripheral 
resistance ;  in  chronic  interstitial  nephritis,  and  is 
very  wide  in  aortic  insufficiency,  in  fact,  it  is  often 
pathognamonic  of  this  condition.  Dr.  George  Oliver 
says  that  of  the  two  he  has  come  to  consider  the 
diastolic  pressure  just  as  precise  as  the  systolic  and 
more  valuable. 


CHAPTER  II. 


THE  CIRCULATION. 

Instruments  for  Study  of  Blood-Pressure 

Practical  Sphygmomanometry 
Physiology  of  the  Circulation 
Arterial  Pressure 
Causes  of  Normal  Pressure 

Terms  and  Definitions  . 

The  Pulse 

Blood-Pressure 

Systolic  Blood-Pressure 
Diastolic  Pressure 
Pulse  Pressure  or  Range 

Mean  Tension     . 

Normal  Tension 

Hypotension 

Hypertension 

Auscultatory  Blood-Pressure 


15 
16 
16 
16 
17 

17 
18 
18 
18 
18 
18 
19 
19 
19 
19 

20 


CHAPTER    II. 
THE  CIRCULATION. 

The  application  of  instruments  of  precision  for  the 
study  of  conditions  of  the  circulation  marks  an  epoch 
in  the  history  of  medicine.  The  application  of  scien- 
tific instruments  in  clinical  medicine  has  developed  a 
large  amount  of  valuable  information  concerning  the 
relation  of  the  heart,  blood-vessels  and  kidneys,  in 
both  normal  and  pathologic  conditions.  We  are  now 
able,  by  means  of  easily  applied  tests,  to  gather  accur- 
ately and  quickly  an  enormous  amount  of  detailed 
information  which  could  have  been  found  by  no  other 
means. 

This  general  increase  in  knowledge  of  special  dis- 
eases has  placed  an  added  amount  of  responsibility 
upon  the  medical  profession,  for  the  public  has  so 
learned  to  appreciate  the  benefit  to  be  derived  from 
this  broader  knowledge,  that  patients  now  demand 
special  methods  of  examination  ?nd  study,  in  every 
case,  far  greater  than  was  ever  dreamed  of  twenty 
years  ago. 

Among  the  many  scientific  instruments  now  em- 
ployed in  the  study  and  practice  of  medicine,  there 
is  probably  not  one  single  instrument  of  greater  use 
and  of  easier  application  than  the  sphygmomanometer. 
Its  value  has  now  become  so  fully  established  that  it 
needs  no  argument  to   show^  an   intelligent  physician 

15 


16  Physiology  of  Circulation. 

that  the  sphygmomanometer  is  a  most  important  part 
of  his  armamentarium. 

In  taking  up  this  discussion  of  blood-pressure 
apparatus  and  blood-pressure  tests,  it  is  only  neces- 
sary to  call  attention  to  the  fact  that  the  normal  circu- 
lation is  a  vital  function  necessary  in  the  maintenance 
of  health  and  that  the  cardio-vascular  system  is 
involved  to  a  more  or  less  degree  in  the  great  majority 
of  diseased  conditions.  It  is  evident  that  the  knowl- 
edge of  the  condition  of  the  heart  and  circulation  plays 
an  important  part,  not  only  in  diagnosis,  but  in  prog- 
nosis and  in  treatment. 

In  taking  up  the  consideration  of  the  subject  of 
blood-pressure,  a  brief  review  of  the  physiology  of 
the  circulation  is  essential  in  order  that  departures 
from  it  may  be  recognized  and  that  these  changes 
may  be  given  their  proper  value  in  the  general  symp- 
tom-complex. 

Roughly  speaking,  the  heart  and  arteries  may  be 
likened  to  a  force  pump  and  series  of  elastic  tubes, 
which  supply  every  part  of  the  body  with  nutrition, 
remove  waste  products  and  at  the  same  time  con- 
tribute to  the  size  and  density  of  the  organs.  The 
heart  is  a  compound  pump  of  intermittent  action. 
From  this  springs  the  aorta,  which  rapidly  ramifies 
from  the  heart  to  the  periphery.  The  aorta  receives 
blood  from  the  heart  in  intermittent  jets,  and  this 
would  be  transmitted  to  the  periphery  in  the  same 
intermittent  manner  were  it  not  for  the  elasticity  and 
other  vital  properties   of  the  blood-vessel  walls. 

The  mechanism  of  the  circulation  is  largely  con- 
cerned in  reducing  this  intermittent  stream  to  the  con- 
tinuous flow  found  in  the  organs  and  capillaries.     It 


Causes  of  Normal  Pressure.  17 

is  also  concerned  in  maintaining^  the  proper  supply  of 
blood  to  each  part  as  the  demand  may  arise  for 
increased  nutrition.  In  order  to  accomplish  this  func- 
tion, it  is  essential  that  the  blood  should  be  maintained 
under  a  certain  degree  of  pressure.  This  is  necessary 
to  insure  the  proper  distribution  and  to  bring  an  in- 
creased supply  to  any  particular  region  when  de- 
manded. This  relation  is  maintained  by  what  is  known 
as  blood-pressure. 

Normal  blood-pressure  depends  upon  the  normal 
correlation  and  interaction  of  certain  variable  factors : 
(1)  The  amount  of  blood  pumped  into  the  arterial 
system  by  the  heart.  (2)  The  resistance  offered  to 
the  escape  of  blood  toward  the  periphery  through  the 
smaller  arteries  and  the  capillaries.  Of  less  import- 
ance are  (3)  the  elasticity  of  the  vessel  walls,  (4)  the 
total  quantity  of  blood  in  the  body,  and  (5)  viscosity. 
These  factors  are  all  capable  of  interaction  in  the 
most  complicated  manner.  For  example,  if  the  arterial 
pressure  is  increased  from  any  cause,  the  vagus  nerve 
is  stimulated,  and  the  effect  of  its  inhibitory  action 
upon  the  heart  is  to  lower  the  heart  rate  so  that  less 
blood  is  delivered  into  the  aorta  in  a  given  time,  thus 
assisting  to  maintain  normal  blood-pressure.  In  like 
manner,  when  the  volume  of  blood  is  rapidly  reduced 
from  hemorrhage  or  venesection,  the  blood-vessel 
reflex  immediately  reduces  the  calibre  of  the  arteries, 
so  that  within  certain  limits  the  blood-pressure  is  not 
altered. 

Terms  and  Definitions. 

Having  briefly  reviewed  the  physiology  of  the  nor- 
mal circulation  and  the  causes  concerned  in  the  pro- 
duction and  maintenance  of  blood-pressure,  we  may 


18  Terms  and  Definitions. 

now  proceed  to  a  consideration  of  the  relation  of 
these  facts  to  the  problems  of  clinical  medicine  and 
their  bearing  on  Diagnosis,  Prognosis  and  Treatment. 

To  obtain  a  clear  insight  and  understanding  of  the 
subject  it  is  all-important  to  have  an  accurate  knowl- 
edge of  the  terms  applied  to  the  matter  under  con- 
sideration. 

The  Pulse. — The  pulse  is  a  rythmically  recurring 
impulse  arising  in  the  systole  of  the  left  ventricle,  and 
palpable  through  the  arterial  system.  Its  presence 
indicates  a  variation  in  blood-tension  within  the  arter- 
ies, which  causes  them  to  pulsate,  as  the  walls  momen- 
tarily expand. 

Blood-pressure. — Blood-pressure  is  the  term  em- 
ployed to  indicate  the  degree  of  pressure  under  which 
the  blood  exists  while  traversing  the  arteries.  Unless 
otherwise  specified,  the ,  term  blood-pressure  as  used 
throughout  this  book  indicates  arterial  systolic  blood- 
pressure. 

Systolic  Blood-pressure.  —  Systolic  blood-pressure 
means  the  degree  of  arterial  pressure  or  lateral  ten- 
sion existing  in  the  arterial  system  at  the  moment  of 
cardiac  systole. 

Diastolic  Blood-pressure. — Diastolic  blood-pressure 
means  the  degree  of  arterial  pressure  or  lateral  ten- 
sion existing  in  the  blood-vessels  just  preceding  a  sys- 
tole of  the  heart.  This  represents  the  time  when  the 
blood-pressure  is  at  its  lowest. 

Pulse-pressure^  Range  or  Amplitude. — These  synony- 
mous terms  indicate  the  amount  of  periodic  variation 
in  blood-pressure  occurring  within  the  arterial  system, 
due  to  the  intermittent  action  of  the  heart.  It  is  equal 
to  the  difference  between  systolic  and  diastolic  blood- 
pressures  as  determined  by  the  sphygmomanometer. 


TkRMS    and    DkI'INMTION' 


10 


Mean  Tension. — Mean  tension  is  the  term  applied  to 
indicate  the  average  strain  to  which  tlie  arterial  sys- 
tem is  subjected.  It  corresponds  closely  to  the  arith- 
metical mean  of  the  systolic  and  diastolic  blood-pres- 
sure. The  relation  between  these  several  terms  ancl 
normal  pulse  tracing  is  shown  in  Fig.  1. 


stolic  ^  135 
nge  ^  40 
astolic  =  95 


Fig.  1 — Normal  pulse  tracing;  showing  relation  of  sys- 
tolic, diastolic,  pulse-pressure  and  mean.  Pulse-pres- 
sure equals  40. 

Normal  Tension. — This  term  applies  to  the  systolic 
blood-pressure  which  should  be  found  in  a  normal 
individual  as  determined  by  the  study  of  a  large  num- 
ber of  persons.  This  pressure  is  modified  by  a 
number  of  normal  or  physiological  conditions,  and 
is  therefore  subjected  to  some  variation.  Full  dis- 
cussion of  these  will  be  taken  up  in  Chapter  I\' 
page  54. 

Hypotension. — Hypotension  is  the  term  applied  to 
the  condition  of  the  circulation  in  which  the  systolic 
blood-pressure  is  found  to  be  below  the  normal  as 
estimated  for  the  individual. 

Hypertension. — Hypertension  is  the  term  applied  to 
a  condition  of  the  blood-pressure  when  the  level  is 
maintained  above  the  estimated  minimum  normal 
pressure. 


20  Terms  and  Definitions. 

Auscultatory  method. — By  this  is  meant  a  method  of 
determining  both  the  systolic  and  diastoUc  blood- 
pressure,  with  the  aid  of  a  suitable  stethoscope  (as 
the  Bowles  Midget  or  the  sphygmometroscope,  see 
page  41),  the  bell  of  which  is  placed  over  the  bifur- 
cation of  the  brachial  artery  at  the  bend  of  the  elbow 
below  the  sphygmomanometer  cuff. 


THE  FAUGHT 

SPHYGMOMANOMETER 

AND    THE 

BOWLES  STETHOSCOPE 

A  clinician  of  national  reputation  has  said  in 

public  that  were  he    to  be    deprived  of  all 

the  aids  to  diagnosis  known  to  medicine  save 

two,  he  would  retain  his  sphygmomanometer 

and  the  stethoscope.   He  uses  a  FAUGHT 

SPHYGMOMANOMETER  and 

the  BOWLES  STETHOSCOPE. 


CHAPTER  III. 
THE  SPHYGMOMANOMETER- 

The  Principle  of  the  Sphygmomanometer 

Circulator  Compression 
Explanation  of  Systolic  Reading 
Explanation  of  Diastolic  Reading 

Description  of  Apparatus      .... 

Mercury  Column  Apparatus 
Aneroid  or  Pocket  Apparatus 
Description  of  Arm-Bands 


21 
22 
22 
23 

24 
25 
28 
31 


Practical  Application  of  Faught  Aneroid  Apparatus  29 

Adjustment  of  Arm-Band  .         .         .  31 

The  Systolic  Reading  ....  36 

The  Diastolic  Reading         ....  37 

Auscultatory  Method  ...  38 

Description  of  Tone  Phases         .  38 

The  Pulse  Pressure 39 

The  Mean  Pressure 39 

The  Sphygmometroscope       .....  40 

Applied  to  Auscultatory  Blood-Pressure     .  41 

The  Multiple-  Sphygmo- Metroscope    .         .  42 

Practical  Application  of  the  Standard  Sphygmoma- 
nometer        .......  43 

Application  of  Arm-Band  ...  43 

The  Systolic  Reading  ....  44 

The  Diastolic  Reading         ....  46 

Fedde  Diastolic  Indicator     ...  47 

Points  to  be  Remembered  in  Making  Tests  48 

Methods  of  Recording  Blood-Pressure  ...  49 

Hospital  Laboratory  Sheet         ...  50 

Faught's  Clinical  Chart      .         .         .         .  51 


22 


Explanation  of  Systolic  Reading. 


Fig.  2,  A  and  B,  shows  the  relation  of  the  com- 
pressing bag  to  the  artery.  In  Fig.  2,  A,  the  pressure 
within  the  cuff  is  greater  than  the  blood-pressure 
within  the  artery,  which  is  therefore  collapsed  and 
the  pulse  in  the  distal  end  of  the  vessel  cut  off.     In 


-Pressure  in  "b"  135  mm.  Hg.;  pressure  in  "a"  130  mm. 
Hg.   B   is   therefore   collapsed,   pulse   cannot  pass. 


B. — Pressure  "b"  129  mm.   Hg.;  pressure  in  "a"  130  mm. 
Hg.  Pulse  passes. 

Fig.  2 — Diagram  of  relations  of  armlet  to  brachial 
artery.  Explanation  of  systolic  reading;  a,  artery;  b, 
compressing  armlet;  c,  retaining  cuff;  d,  tube  to  mano- 
meter; e,  humerus. 

Fig.  2,  B,  the  pressure  in  the  cuff  has  been  reduced 
so  that  it  is  a  fraction  of  a  millimeter  less  than  the 
systolic  pressure  within  the  vessel.  Now  at  each 
systole  a  small  amount  of  blood  will  pass  the  con- 


Explanation  of  Diastolic  Reading. 


23 


striction  and  will  reach  the  distal  end  of  the  artery, 
where  the  wave  can  be  felt  by  the  palpating  finger 
at  the  wrist. 


A. — Systolic  pressure  in  "a"  130  mm.  Hg.;  pressure  in  "b' 
101  mm.  Hg.     Artery  not  compressed. 


B. — Diastolic  pressure  in  "a"  100  min.  Hg.;  pressure  in 
"b"    101    mm.    Hg.     Artery   collapsed. 

Fig.  3 — Diagram  of  relation  of  armlet  to  brachial  artery. 
Explanation  of  diastolic  reading;  a,  artery;  b,  com- 
pressing armlet;  c,  retaining  cuff;  d,  tube  to  mano- 
meter;  e,   humerus. 


Fig.  3,  A  and  B,  represents  the  conditions  existing 
between  the  constricting  cuff  and  the  vessel  at  the 
time  of  diastolic  pressure.  A  represents  a  pressure 
within  the  cuff  less  than  the  systolic  pressure  in  the 


24  Methods  of  Reading. 

vessel.  This  is  insufficient  to  affect  the  vessel  during 
the  systolic  period.  B  shows  the  artery  and  cuff  dur- 
ing the  diastolic  period,  when  the  pressure  within  the 
artery  is  at  its  lowest  point,  a  fraction  of  a  millimeter 
less  than  the  pressure  v/ithin  the  cuff.  Consequently 
the  artery  is  collapsed  at  this  time.  The  effect  of 
each  succeeding  systole  is  to  alternate  between  a 
round  and  a  flat  vessel  at  the  point  of  compression. 
This  aft'ects  the  pressure  of  the  air  within  the  cuff, 
w^hich  is  in  turn  transmitted  to  the  mercury  column 
of  the  manometer  and  becomes  visible  in  the  rhythmic 
fluctuation  of  the  column  of  mercury  which  is  syn- 
chronous with  the  pulse  beat.  Since  the  fluctuation 
will  reach  a  maximum  at  the  time  when  the  pressure 
in  the  cuff  is  approximately  equal  to  the  diastolic 
pressure  in  the  vessel,  we  are  justified  in  considering 
the  base  of  the  manometer  column  at  this  time  a 
measure  of  the  diastolic  pressure  within  the  vessel. 

Since  the  development  of  the  visual  or  oscillatory 
method  of  diastolic  blood-pressure  observations  newer 
and  better  methods  have  been  designed.  These  are 
the  tactile,  the  auscultatory  and  that  by  means  of  the 
Fedde  indicator  attachment.  Each  of  which  will  be 
considered  more  fully  later  under  the  head  of  ''appli- 
cation of  the  blood-pressure  test." 

Description  of  Apparatus. — At  the  present  time  the 
market  is  flooded  with  instruments  of  all  descriptions 
for  estimating  blood-pressure,  so  that  it  is  important 
that  the  prospective  purchaser  should  be  able  to 
separate  the  good  from  the  bad,  since  the  imperfect 
and  poorly  constructed  instrument  will  be  a  constant 
source  of  inconvenience  and  may  give  very  incorrect 
readings. 


Mercury  Api'aratus. 


25 


All  these  instruniciils  may  be  roughly  divided  into 
two  classes :  First,  those  dej)endent  upon  the  weight 
of  a  fluid  column  (usually  mercury)  which  measures 
the  pressure ;  and,  second,  those  employing  some  form 
of  spring  or  aneroid  chamber. 


Fig.  a — Type  of  Mercury  IManometer  employing  a  verti- 
cal tube.  A,  mercury-containing  base;  B,  manometer 
tube;  C,  tube  to  armlet;  D,  tube  to  bellows;  E,  scale. 

Taking  up  the  first  class,  we  find  that  this  can  be 
divided  into  two  divisions;  one  employs  a  vertical 
glass  tube  emerging  from  the  mercury  chamber  so 
that  when  pressure  is  exerted  on  the  mercury,  it  is 
forced  upward  into  the  glass  tube,  where  the  pressure 
is  indicated  in  millimeters  of  mercury  by  an  appropri- 
ate scale  attached  thereto  (see  Fig.  4). 


26 


Faught-Pilling  Sphygmomanometers. 


The  second  group  of  mercury  instruments  employ 
a  glass  U-tube  similar  to  that  first  used  by  Poiseuille 


Fig.  5  —  Manometer  Ar-FiG.  6 — ]\Ianometer  Ar- 
rangement of  Pilling  Spe-  rangement  of  Faugh  t 
cial  Sphygmomanometer.  Standard    Sphygmomano- 

meter. 

(see  Fig.  6),  with  the  open  ends  up.  This  tube  is 
partly  filled  with  mercury  and  one  limb  is  connected 
by   means    of    suitable   tubing   with   the    rest   of   the 


Accuracy  of  Mercury  Apparatus.  27 

apparatus.  Pressure  exerted  within  the  system  will 
cause  the  mercury  to  rise  in  one  limb  of  the  tube  with 
a  proportionate  fall  upon  the  other.  The  difference 
in  the  level  of  the  mercury  in  the  two  limbs  will  repre- 
sent the  pressure,  which  may  be  measured  by  a  suit- 
able scale  placed  between  the  tubes. 

These  two  types  depending  upon  a  vertical  column 
of  mercury  have  little  to  choose  between  them,  and 
both  are  accurate  and  trustworthy  at  all  times.  The 
mercury  at  rest  freely  communicates  with  the  atmos- 
phere, and  is  therefore  not  afifected  by  barometric  or 
thermometric  changes. 

A  question  has  been  raised  by  some  regarding  the 
accuracy  of  the  cystern-vertical-tube-type  of  mercury 
sphygmomanometer  in  the  high  readings.  It  has  been 
found  that  the  fall  in  the  mercury  level  in  the  cystern 
affects  slightly  the  total  height  of  the  mercury  column, 
so  that  in  readings  above  250  the  figure  obtained 
with  this  type  of  apparatus  may  be  from  5  to  10  mm. 
too  low.  After  all,  this  is  not  such  a  great  draw- 
back, as  the  variation  is  slight  at  best,  and  because 
such  pressures  are  but  rarely  met  in  the  course  of 
general  practice. 

Value   of    Mercury   Apparatus    in    Determining 
Diastolic  Pressure. 

Some  time  ago  there  appeared  an  article  in  which 
the  value  of  the  fluctuation  of  the  mercury  column 
for  determining  diastolic  pressures  was  questioned ; 
this  was  based  upon  the  supposed  interference  of  the 
inertia  of  the  mercury  column.  The  author  of  these 
statements  failed  to  recognize  the  fact  that  the  mer- 
cury column  at  the  time  of  the  observation  was  under 


28  Faught  Pocket  Sphygmomanometer. 

an  added  factor  of  pressure  and  that  this  pressure 
exerted  against  the  mercury  column  greatly  reduced 
the  enertia  factor.  By  experiment  it  was  found  pos- 
sible for  the  mercury  column  to  shozv  a  fluctuation 
from  successive  systolies  up  to  nearly  200  heats  per 
minute,  or  more  than  twice  the  number  possible  with 
a  mercury  column  moving  freely  in  the  atmosphere. 
Anyone,  by  actual  experiment,  can  demonstrate  this 
with  any  form  of  mercury  apparatus,  so  that  one 
need  not  fear  to  use  a  mercury  apparatus  when  em- 
ploying the  visual  method  for  diastolic  reading,  unless 
the  pulse  is  so  rapid  that  it  is  uncountable;  this  does 
not  mean  that  the  visual  method  is  recommended,  but 
simply  that  when  no  other ,  means  is  available,  the 
results  by  this  method  will  be  reasonably  accurate 
and  clinically  satisfactory. 

Aneroid  or  Pocket  Type. — There  are  also  several 
types  of  instrument,  employing  some  form  of  spring 
and  aneroid  chamber,  actuating  a  dial  indicator  for 
the  recording  of  blood-pressure  in  millimeters  of 
mercury.  These  are  the  so-called  pocket  instruments, 
and  have  much  to  recommend  them,  provided  they 
do  not  become  inaccurate  by  use. 

The  Faught  Pocket  Sphygmomanometer  consists  of 
a  gold-plated  aneroid  gauge  with  a  white  enamel  dial 
bearing  black  and  red  markings  graduated  to  300  mm. 
Hg.,  a  strong  flexible  sleeve  and  a  metallic  inflating 
pump,  together  with  suitable  rubber  tubing  for  con- 
nections. Vv^hen  assembled  these  constitute  a  very 
simple  and  most  reliable  instrument,  so  compact  that 
it  is  contained  in  a  leather  case,  measuring  8  x  3^  x 
1^  inches,  and  weighing  complete  about  one-half 
pound,  fitting  easily  in  the  pocket  or  bag. 


Accuracy  of  Pocket  Sphygmomanometers.  29 

This  instrument  has  been  devised  to  fill  the  long- 
felt  need  of  a  Pocket  Sphygmomanometer,  which 
would  combine  portability  and  accuracy  with  durabil- 
ity and  strength.  The  Faught  Pocket  Sphygmomano- 
meter is  an  exact  and  efficient  instrument,  and  is 
employed  extensively  by  life  insurance  examiners, 
hospitals,  the  army  and  navy,  bureaus  of  health  and 
by  most  of  the  leading  practitioners.  It  is  compact, 
absolutely  accurate,  very  sensitive,  substantially  con- 
structed, and  with  ordinary  care  should  last  a  life- 
time. 

It  is  unfortunate  for  the  medical  profession  that 
a  certain  type  of  aneroid  type  of  instrument  which 
at  first  met  with  favor  has  been  found  in  many  cases 
to  lose  its  accuracy  and  to  become  untrustworthy 
through  frailty  of  construction,  which  renders  it 
easily  deranged.  Even  ordinary  use  will  at  times 
develop  in  this  particular  make  of  instrument  perma- 
nent inaccuracy. 

Failure  of  a  single  type  should  not,  however,  con- 
demn all  instruments  operating  upon  the  aneroid 
principle,  as  the  test  of  time  so  far  has  failed  to  show 
any  such  disturbance  in  the  aneroid  made  by  the 
Pilling  Company;  for  example,  a  Faught  instrument 
was  used  for  ward  class  demonstration  for  more 
than  a  year,  and  when  tested  with  the  original  stand- 
ard mercury  column  was  found  as  absolutely  accurate 
as  zvhen  originally  tested.  At  another  time,  after  one 
hour's  constant  use  on  about  twenty  students,  a  test 
for  accuracy  was  immediately  made,  and  the  readings 
corresponded  absolutely,  both  up  to  300  and  down 
again.  This  proves  conclusively  that  the 
Faught    Pocket    Sphygmomanometer   is    not   af- 


30  Durability  of  Faught  Sphygmomanometers. 

FECTED    BY    CONSTANT    USE    AND    THAT    READINGS    BOTH 

UP  AND  DOWN  ARE  IDENTICAL.  No  Other  ancroid  can 
bear  these  tests. 

J.  F.  Prendergast,  commenting  upon  the  accuracy  of 
the  Faught  Pocket  Sphygmomanometer,  states :   "As 

FOR  ACCURACY  AND  DURABILITY,  THE  WRITER  HAS  FOR 
THE  PAST  FOURTEEN  MONTHS  USED  ONE  ANEROID  IN- 
STRUMENT, A  Faught,  and  has  forced  it  up  to  450 

MM.  nearly  TWO  THOUSAND  TIMES.  AfTER  THIS 
SEVERE  TEST  IT  WAS  COMPARED  WITH  A  STANDARD 
MERCURY  COLUMN  AND  FOUND  AS  ACCURATE  AS  AT  THE 
ORIGINAL  TEST.  It  IS  STILL  IN  SPLENDID  WORKING 
CONDITION,  AND  THE  COMPRESSION  DIAPHRAGMS  ARE 
AS  RESILIENT  AS  THE  DAY  IT  LEFT  THE  PiLLING  FAC- 
TORY.   This  is  a  test  of  the  most  severe  character, 

AND  ANY  INSTRUMENT  THAT  WILL  REMAIN  ACCURATE 
WITH  SUCH  USAGE  WILL  LAST  INDEFINITELY  WITH 
ORDINARY  USE." 


Fig.  7. — Faught  Pocket  Sphygmomanometer  in  Case. 

A  very  important  and  distinctive  feature  possessed 
by  the  Faught  Pocket  Sphygmomanometer  and  found 


The  Flexible  Arm-Band.  31 

in  no  other  instrument  of  similar  character  is  the  abso- 
lute elimination  of  the  so-called  "fatigue  of  metal" 
which  heretofore  has  interfered  with  the  accuracy  of 
all  other  aneroid  instruments.  By  persistent  experi- 
ment and  painstaking  study  a  material  for  the  con- 
struction of  the  compression  disks  has  been  found 
which  is  not  affected  in  any  way  by  temperature  or 
pressure  variations. 

These  tests  can  be  repeated  by  anyone  and  the 
results  will  be  the  same.     Try  them  and  be  convinced. 

The  Arm-band  is  made  of  strong  grey  inelastic,  but 
soft  and  flexible  material,  having  between  its  layers  a 
rubber  bag  9  x5  inches.  This  measurement  conforms 
to  the  requirements  of  Janeway  and  others,  and  has 
been  found  to  give  the  most  accurate  readings  under 
all  conditions. 


Fig.  8. — Arm-band. 

The  Faught  Pocket  Sphygnioinaiwiueter  can  be 
applied  or  removed  in  less  than  thirty  seconds.  The 
lime  required  to  apply  the  instrument,  make  a  careful 
observation  of  the  pressure  and  remove  it  is  less  than 
consumed  by  any  other  form  of  sphygmomanometer 
on  the  market. 

Two  years'  experience  with  the  Faught  Pocket 
Sphygmomanometer     has     demonstrated    conclusively 


32 


Faught  Pocket  Sphygmomanometers. 


the  superiority  of  the  internal  mechanism  of  this  in- 
strument as  compared  with  all  other  types  of  aneroid. 
They  have  been  found  practically  indestructible  as 
well  as  uniformly  correct.  Many  instruments  in  con- 
stant use — thousands  of  times — coming  back  for 
examination,  are  found  to  have  retained  their  accur- 
acy when  compared  with  the  standard  mercury 
column. 


Fig.  9. — Pocket  Indicator.     Actual  size. 

For  accuracy  and  sensitiveness,  the  Faught  aneroid 
has  all  the  advantages  of  the  best  mercurial  instru- 
ments ;  for  compactness  and  durability  it  far  surpasses 
them.  It  is  practically  indestructible,  and  is  well 
adapted  to  use  in  the  operating  room  and  in  private 
practice,  as  well  as  in  hospital  service. 


Faught  Clinical  Sphygmomanometer. 


33 


Reads  up  to  300  mm. — The  dial,  which  is  accurately 
graduated,  reads  in  mm.  Hg.,  as  does  the  standard 
mercury  column,  each  interval  representing  two  mm., 
and  ranges  from  zero  to  three  hundred   (Fig.  9). 

The  dial  also  may  be  revolved  without  interfering 
with  the  internal  mechanism,  so  that  the  pointer  at 
rest  can  be  adjusted  to  zero.  Neither  temperature 
nor  atmospheric  variation  in  any  zvay  affects  the 
apparatus,  since  when  at  rest  the  pressure  on  both 
side  of  the  pressure  chambers  is  equalized. 


Fig.    10. — Clinical    Pocket    Sphygmomanometer.      One-half 
actual  size.     Diameter  of  dial,  ?>%  inches. 

The  latest  development  in  sphygmomanometers  is 
the  "Faught  Clinical."  This  instrument  follows  a  new 
principle  which  has  been  fully  tried  during  several 
years  in  the  Faught  Pocket  Indicator,  and  which  has 
been  fully  demonstrated  to  be  the  most  desirable  and 
accurate  multiple  chamber  aneroid  instrument  yet 
designed. 

This  instrument  is  shown  in  detail  in  Fig.  10. 


34  Standard  Mercury  Sphygmomanometer. 

The  two  characteristic  features  of  this  instrument 
are  the  large,  easy-to-read  dial,  measuring  3^  inches 
working  diameter,  and  a  graduated  scale  with  a  range 
of  350  mm.  Hg.  The  first  and  only  sphygmomano- 
meter to  have  a  range  sufficient  to  give  accurate  read- 
ings in  every  case,  as  it  is  now  well  established  that 
pressures  are  not  infrequently  encountered  that  regis- 
ter well  above  300  mm.  (See  article  in  New  York 
Med.  Jour.,  June  11,  1910,  by  John  C.  Hirst.) 

In  general  appearance  the  Clinical  very  much 
resembles  the  Pocket  and,  in  spite  of  the  larger  scale, 
is  contained  complete  with  pump  and  arm-band  in  a 
case  but  very  little  larger  than  that  of  the  Pocket 
Indicator. 

The   Faught   Standard   Mercury   Sphygmomanometer   is 

modeled  after  the  U-tube  type  of  apparatus  and  is 
designed  to  overcome  the  defects  of  the  earlier  instru- 
ments, to  meet  every  requirement  demanded  of  a  mod- 
ern sphygmomanometer  and  at  the  same  time  be  easy 
to  use,  difficult  to  derange  and  as  light  and  portable  as 
is  compatible  with  accuracy  and  strength. 

The  mahogany  case,  which  encloses  the  complete 
apparatus,  including  the  arm-band  (see  Fig.  11)  and 
pump  (see  Fig.  16),  measures  4x4^  x  16  inches  and 
weighs  3  pounds  9  ounces.  The  lid  is  hinged  at  one 
end  and  when  raised  supports  the  working  parts  of 
the  apparatus.  A  spring  check  allows  the  lid  to  be 
raised  to  a  vertical  position,  where  it  is  automatically 
held  locked  during  the  observation. 

The  "U"  tube  is  provided  with  a  scale  which  has 
been  arranged  to  give  the  reading  directly  in  milli- 
meters of  mercury. 


Faught  Mercury   Sph  ycmomaxomftkh. 


35 


A  special  and  distinctive  feature  of  the  apjjaralus 
is  the  means  of  preventing  loss  of  mercury  from  the 
manometer  tube  when  the  instrument  is  not  in  use. 
This  is  accomplished  by  means  of  two  small  cocks 
placed  at  either  extremity  of  the  "U"  tube,  and  which 
are  kept  closed  wlien  the  apparatus  is  not  in  use  (see 
Fig.  6). 


Fig.  11 — Faught  Standard  Sphygmomanometer. 


By  eliminating  all  detachable  parts,  the  time  re- 
quired to  make  the  reading  is  reduced  to  a  minimum. 
The  only  preliminaries  to  the  test  being  to  lift  the  lid, 
open  three  cocks  and  attach  two  tubes  to  their  respec- 
tive nipples. 


Z6 


To  Obtain  a  Systolic  Reading. 


To  Operate  the  Faught  Pocket  and  the  Faught 
Clinical  Sphygmomanometers. 

Apply  the  arm-band  to  the  bared  arm  of  the  patient, 
above  the  elbow,  by  placing  the  broad  end,  containing 
the  rubber  bag,  over  the  region  of  the  brachial  artery. 
Wrap  the  rest  of  the  band  as  you  would  a  bandage 
about  the  arm  (see  Fig.  12)  and  tuck  the  narrow 
end  in  under  the  first  turn.  Attach  the  indicator  to 
the  hook  provided  for  that  purpose;  attach  the  pump 
to  one  nipple,  and  the  tube  from  the  arm-band  to  the 


Fig.  12. — Pocket  Indicator  Applied  to  Arm. 

other.  See  that  the  needle  valve  on  the  pump  is  fully 
closed.  Hold  the  pump  in  one  hand  and  locate  the 
pulse  at  the  wrist  with  the  other.  You  are  now 
ready  to  take  the  systolic  pressure. 

To  obtain  systolic  reading. — Pump  sufficient  air  in 
the  system  to  obliterate  the  pulse,  then  by  a  fraction 
of  a  turn  open  the  valve  (see  Fig.  12),  gradually 
release  the  air  pressure,  and  note  the  pressure  indi- 
cated when  the  first  pulse  beat  returns  to  the  wrist. 
This  is  systolic  pressure.  Repeat  the  procedure  one 
or  more  times  to  insure  correct  readings.  Work 
rapidly,  as  prolonged  pressure  upon  the  arm  will  affect 
the  reading. 


To  Obtain  a  Diastolic  Reading.  Zl 

To  obtain  diastolic  reading. — Again  obliterate  the 
pulse  and  allow  the  air  pressure  to  gradually  fall 
through  the  needle-valve.  As  the  pressure  falls  the 
needle  will  be  seen  to  fluctuate  in  rhythm  with  the 
pulse ;  after  a  time  this  movement  will  become  less 
and  eventually  disappear.  The  pressure  indicated 
on  the  dial  at  that  time  will  be  the  diastolic  pressure. 

Obliterate  the  radial  pulse,  then  gradually  reduce 
the  air  pressure ;  when  the  pulse  returns  to  the  wrist 
it  will  at  first  be  very  feeble  and  thready,  then  it  will 
come  up  full  and  strong  under  the  finger.  Take  the 
reading  at  the  moment  the  pulse  becomes  full  and 
normal  in  character.  This  will  be  the  diastolic 
pressure. 

The  value  of  correctness  of  the  ausculatory  method 
of  determining  blood-pressure  has,  during  the  last 
few  years,  been  conclusively  demonstrated.  This  was 
first  introduced  by  Korotokoff,  of  St.  Petersburg,  in 
1905,  who,  instead  of  using  the  finger  upon  the  radial 
pulse,  substituted  the  stethoscope  applied  over  the 
brachial  artery  at  the  bend  of  the  elbow.  On  the 
return  of  the  blood  under  the  armlet,  a  distinct 
throbbing  becomes  audible,  which  gradually  increases 
in  loudness  as  the  pressure  in  the  cuff  lessens,  and 
then  gradually  dies  down  and  disappears  when  the 
artery  ceases  to  be  obstructed  at  any  time  during  the 
heart  cycle. 

The  chief  advantage  of  the  auscultatory  or  auditory 
method  is  in  that  it  gives  not  only  the  high  point — 
the  systolic  pressure — very  definitely,  but  also  the  low 
point — or  diastolic  pressure,  a  point  of  great  value, 
since  it  is  well  recognized  that,  under  many  condi- 
tions by  the  older  methods,  it  is  impossible  to  obtain 


38  Auscultatory  or  Auditory  Method. 

any  accurate  diastolic  pressure,  and  in  some  cases  no 
diastolic  reading  at  all. 

The  importance  of  this  is  further  emphasized  by 
the  fact  that  the  diastolic  pressure  is  often  the  more 
important  reading,  since  it  gives  the  pulse  pressure  or 
amplitude,  which  is  an  indication  of  the  actual  force 
and  volume  of  the  circulation.  Clinical  studies  by 
Goodman  and  Howell  in  the  American  Journal  of 
Medical  Science,  1911,  and  by  Warfield  and  by  H.  G. 
Armstrong  in  the  Journal  of  the  A.  M.  A.  and  British 
Medical  Journal,  are  sufficient  to  assure  us  of  the 
value  of  the  auscultatory  method.  For  the  benefit  of 
those  who  desire  to  go  into  this  study  more  exten- 
sively than  is  really  necessary  for  clinical  work,  the 
following  analysis  of  the  sounds  is  given. 

These  consist  of  five  phases,  which  are  clean  cut  and 
which  have  a  definite  relation  to  the  differences  be- 
tween the  extremes  of  pressure.  With  a  normal 
systolic  pressure  at  130  mm.  and  a  diastolic  pressure 
at  85,  the  phases  are : 

First,  a  loud,  clear,  snapping  tone,  which  is  the 
first  phase.  This  serves  as  an  index  as  to  how  far 
the  pressure  must  fall  before  the  column  of  blood 
can  be  sustained  past  the  obstruction  in  the  vessel 
caused  by  the  cuff,  at  sufficient  velocity  and  for  suf- 
ficient duration  to  produce  the  murmur.  Normally 
this  phase  covers  14  mm.,  and  any  increase  or  decrease 
in  length  should  be  noted.  The  advent  of  this  sound 
indicates  the  systolic  pressure. 

The  Second  Phase  consists  of  a  succession  of  mur- 
murs, covers  20  mm.  and  is  dependent  upon  cardiac 
effectiveness. 


The  Mean  Pressure.  3^ 

The  Third  Phase  is  a  tone  resembling  the  first  phase, 
but  less  marked  and  lasts  5  mm.  This  is  dependent 
upon  cardiac  efficiency  and  also  upon  the  character 
of  the  vessel  wall.  The  more  sclerotic  the  vessel  and 
the  greater  the  cardiac  hypertrophy,  the  more  favor- 
able are  the  conditions  for  the  production  of  a  clear 
tone  at  this  time. 

The  Fourth  Phase  occupies  about  6  mm.  and  is  heard 
as  a  dull  tone ;  a  resilient  vessel  receiving  a  normal 
pulse  shock,  or  a  rigid  vessel  receiving  a  weakened 
shock.  The  pointer  at  this  time  indicates  the  diastolic 
pressure. 

The  Fifth  Phase  is  the  disappearances  of  all  the 
sounds. 

Of  these  three  methods,  the  last  is  the  more  accu- 
rate and  scientific.  One  point,  however,  must  be 
borne  in  mind :  readings  in  the  text  books  and  medical 
literature  are  based  on  the  first  and  second  methods. 
The  auscultatory  method  will  give  readings  of  a  slightly 
higher  systolic  pressure  and  a  diastolic  pressure  of 
10  to  15  mm.  lower. 

Having  determined  the  systolic  pressure  and  the 
diastolic  pressure,  the  diastolic  pressure  is  subtracted 
from  the  systolic  pressure  and  the  remainder  is  the 
pulse-pressure  (see  Fig.  1,  page  ig). 

To  obtain  the  mean  pressure,  add  one-half  of  the 
pulse-pressure  to  the  diastolic  pressure   (see  Fig.   1), 

In  order  to  enable  physicians  to  take  the  blood- 
pressure  readings  more  accurately  and  to  make  them 
of  greater  clinical  value  to  the  profession  as  a  diag- 
nostic and  therapeutic  guide,  Dr.  J.  F.  Prendergast 
{N.  Y.  Med.  Jour.,  Jan.  11,  1913)  has  had  devised  and 
placed  on  the  market  the  Sphygmometroscope  (Aus- 


40 


The  Sphygmo-Metroscope. 


culoscope).  It  consists  of  a  two-inch  band,  to  which 
is  attached  a  metal  bowl  or  cup,  the  face  of  which 
has  a  very  delicate  diaphragm,  with  a  centre  projec- 
tion to  fit  more  snugly  to  the  surface  of  the  arm  over 
the  brachial  artery,  just  at  or  below  the  bend  of  the 
elbow.     Flexible  rubber  tubes  are  connected  with  the 


Fig.     13. — Method     of    auscultatory    blood-pressure    test, 
using  Faught  pocket  indicator  and  sphygmometroscope. 


drum  or  body  of  the  instrument,  to  which  are  attached 
hard-rubber  ear-pieces  (see  Fig.  14).  It  is  called 
the  Bowles  sphygmometroscope,  and  resembles  the 
Bowles  stethoscope  with  certain  modifications;  it  is 
attached  to  the  arm  by  a  two-inch  band. 

The  instrument  is  intended  for  use  with  any  kind 
or  form  of  sphygmomanometer,  either  pocket  or 
mercury.  Its  method  of  application  is  to  place  the 
band  on  the  arm  one  or  two  cm.    (one-half  to  one 


The  S'phygmo-Metroscope. 


41 


inch)  below  the  arm-l)an(l  or  cuff  of  the  sphygmoman- 
ometer at  the  bend  of  the  elbow,  having  the  projection 
on  the  diaphragm  of  the  drum  directly  over  the 
brachial  artery  before  it  divides  into  the  ulnar  and 
radial.  Care  should  be  taken  to  avoid  pressure  from 
this  band  upon  the  arm. 


Fig.    14. — Sphygmometroscope. 

Pump  the  cuff,  connected  with  the  manometer, 
with  air  until  the  radial  pulse  is  cut  off,  open  the 
release  valve  and  allow  the  air  to  escape  slowly  from 
the  arm-band.  The  first  impulse  or  sound  heard 
is  a  clear  thump  or  tap,  caused  by  the  sudden  stretch- 
ing of  the  walls  of  the  relaxed  vessel  and  the  rapidity 
of  the  blood  stream.     This  is  the  systolic  pressure. 

Where  one  is  merely  trying  to  read  the  systolic 
and  diastolic  pressures,  it  is  not  necessary  to  attempt 
to  interpret  the  different  phases.  The  essential  thing 
to  remember  is  that  the  first  tap  or  sound  is  the  systolic 
pressure,  and  just  at  the  disappearance  of  all  sounds 
is  the  diastolic  pressure. 


42  The  Multiple  Sphygmo-Metroscope. 

Goodman  and  Howell  say:  "The  auscultatory 
method  is  useful  in  differentiating  certain  organic  and 
functional  derangements.  It  was  found  that  any 
arrhythmia  which  may  be  present  is  noted  earlier  by 


Bowles  \    I     \  /multiple 
Sphymo^metroi^scope 


Fig.   15. — The  Multiple   Sphygmometroscope. 

the  auscultatory  method  than  by  feeling  the  pulse  or 
listening  to  the  heart.  By  this  method  true  organic 
cardiac  lesions  can  be  differentiated  from  a  neurosis. 
In  organic  lesions  there  is  a  uniformity  in  sequence 
of  readings ;  in  neuroses  the  readings  are  marked  by 
variations  in  sequence  and  a  variation  in  the  systolic 
and  diastoHc  pressures." 

The  Multiple  Sphygmometroscope. — The  accompany- 
ing illustration,  Fig.  15,  represents  a  new  device  to 
facilitate  the  teaching  of  blood-pressure  readings  by 
the  auscultatory  method.  The  chief  drawback  to  the 
ausculatory  method  has  been  the  seeming  difficulty 
which  the  average  physician  has  in  learning  to  per- 
ceive and  interpret  the  sounds  heard  over  the  artery. 


Opkration  of  Standard  Sphygmomanometer.  43 

Tlie  idea  suggested  itself  that  if  the  si)hygmometro- 
scope  were  made  into  a  multiple  of  four,  whereby 
the  sounds  could  be  heard  by  more  than  one  individual 
at  the  same  time,  it  would  overcome  this  difficulty 
and  make  it  possible  for  anyone  familiar  with  the 
sounds  heard  during  auscultatory  blood-pressure  ob- 
servations to  direct  the  attention  of  a  small  group  of 
observers  during  the  actual  performance  of  the  test. 

The  G.  P.  Pilling  Company,  of  Philadelphia,  have 
taken  up  this  suggestion,  and  this  valuable  instrument 
is  now  upon  the  market. 

The  device  will  be  valuable  particularly  to  the 
medical  teacher,  as  it  has  been  our  experience  that 
many  students  go  through  their  clinical  studies  with- 
out ever  actually  hearing  or  seeing  what  is  demon- 
strated. It  is  serviceable  also  in  demonstrating  to  med- 
ical societies  or  groups  of  medical  men  conditions  in- 
volving marked  variations  in  pressure. 

To    Operate   the    Standard    Sphygmomanometer. 

The  patient  should  be  in  a  comfortable  position 
and  in  a  sitting  or  reclining  posture.  The  instrument 
should  be  upon  a  level  surface  within  easy  reach  of 
the  examiner. 

The  lid  is  then  raised  until  it  locks  in  a  vertical 
position.  If  the  tube  from  the  pump  is  not  already 
connected  to  the  nipple  F,  it  should  be  firmly  attached 
to  it.  The  two  mercury  guard  cocks  K  and  L  at 
the  ends  of  the  ''U"  tube  should  be  opened  and  the 
escape  valve  N  tightly  closed. 

The  hollow  rubber  bag  of  the  arm-band  A  should 
be    firmly    wrapped    around    the    bared    arm    of    the 


44 


Systolic  Reading. 


patient  and  securely  bound  there  by  the  leather  cuff 
and  straps  B  (see  page  89).  The  cuff  should  be 
applied  snugly,  but  not  with  pressure,  as  it  is  not  de- 
signed to  compress  the  member,  but  only  to  restrain 
the  inner  rubber  bag  while  pressure  is  applied  to  it. 
The  tube  from  the  arm-band  C  is  attached  firmly  to 
the  nipple  D.    The  cock  in  the  nipple  F  is  opened. 


Fig.  16. — A,  inner  arm-bag.  B,  outer  retaining  cuff.  C, 
tube  from  arm-band.  D,  nipple  for  tube  from  arm- 
band. P,  pump.  F,  nipple  for  pump  tube.  G,  milli- 
meter scale.  H,  manometer  tube.  I,  link-brace  and 
lock.  K,  mercury  guard  cock.  L,  mercury  guard  cock. 
M,  pressure  guard  cock.     N,  release  valve. 

This  arrangement  forms  a  continuous  closed  pneu- 
matic system  communicating  freely  with  the  mano- 
meter tube  of  the  instrument.  Now  when  pressure 
is  raised  in  the  arm-band  by  the  hand-pump,  the 
amount  of  force  exerted  is  indicated  by  the  rise  of 
the  right-hand  column  in  the  manometer  tube  H,  the 
height  of  which  will  be  indicated  on  the  scale  G  in 
millimeters  of  mercury. 

Systolic  Reading. — With  one  hand  find  the  pulse  at 
the  wrist  of  the  arm,  to  which  the  arm-band  has  been 


Systolic  Reauinc:. 


45 


applied.  The  fingers  should  be  in  a  comfortable  posi- 
tion and  under  no  circumstance  should  be  moved 
during  the  observation.  Care  should  also  be  observed 
that  the  pulse  is  not  cut  off  by  undue  pressure  of  the 
palpating  fingers.  The  cuff  should  be  in  the  same 
horizontal  plane  as  the  subject's  heart. 


ANEROID 


Fig.    17. — Diagram  of  internal   mechanism,   showing  com- 
pression chambers. 

Note  the  fact  that  in  this  instrument  the  pressure  itself 
is  applied  on  the  outside  of  the  metallic  chambers,  so 
that  they  are  compressed  and  not  expanded,  in  propor- 
tion to  the  degree  of  compression  force  exerted. 

While  the  pulse  is  thus  under  observation,  the 
pressure  in  the  apparatus  is  raised  by  means  of  the 
hand  bellows  or  pump  until  the  pressure  within  the 
constricting  band  is  sufficient  to  prevent  the  impulse 
from  reaching  the  wrist.  When  this  is  accomplished 
the  cock  in  the  nipple  M  is  closed  to  eliminate  the 
elastic  pressure.  Now  by  a  fraction  of  a  turn  in  the 
valve  N  the  pressure  in  the  system  is  slowly  released. 
During   this    part   of    the   procedure,    a    close    watch 


46  The  Diastolic  Reading. 

should  be  kept  upon  the  height  of  the  mercury  column 
and  for  the  return  of  the  first  pulse  beat  at  the  wrist. 
The  level  of  the  mercury  column  at  the  instant  that 
the  pulse  passes  the  compression-band  will  represent 
the  systolic  pressure  in  the  vessel  under  observation. 
It  is  advisable  to  repeat  this  procedure  a  few  times 
to  check  the  correctness  of  the  finding. 

The  diastolic  pressure  may  be  obtained  in  several 
ways.  The  method  employed  will  depend  upon  the 
character  of  the  instrument  used  and  the  method 
preferred  by  the  operator.  The  readings  obtained 
by  this  instrument  correspond  closely  to  those  obtained 
by  auscultation.  The  methods  will  be  described  in 
the  order  in  which  they  have  been  devised. 

The  visual  method  depends  on  the  to-and-f  ro  motion 
imparted  to  the  mercury  in  the  "U"  tube,  which  occurs 
after  the  pressure  has  fallen  below  the  systolic  point. 
Having  determined  the  systolic  pressure,  again  raise 
the  pressure  to  a  few  millimeters  above  this  point  and 
immediately  close  the  valve  M.  Now  allow  the  pressure 
to  fall  very  slowly  by  releasing  the  air  through  the 
valve  N. 

As  the  mercury  falls  below  the  systolic  point  it  will 
be  noted  that  it  acquires  a  rhythmic  motion  corre- 
sponding in  time  to  the  pulse.  This  will  be  found  to 
gradually  increase  in  amplitude  up  to  a  certain  point, 
after  which  it  decreases  and  finally  ceases  before  zero 
pressure  is  reached.  During  this  gradual  fall  the 
base  of  the  mercury  column,  when  the  mercury  is 
making  the  greatest  excursion,  represents  the  diastolic 
pressure. 

These  are  the  same  as  are  described  under  Pocket 
Apparatus  on  page  36. 


The  Fedde  Indic. 


47 


By  Diastolic  Indicator. — This  is  very  similar  lo 
the  visual  method,  except  that  the  movement  of  the 
mercury  column  is  ignored  and  the  movement  of  the 
pith  ball  in  the  small  vertical  tube  relied  upon  to  de- 
termine the  diastolic  pressure. 

By  reference  to  Fig.  18  it  will  be  noted  that  the 
narrow  perpendicular  glass  tube  contains  a  small, 
light  ball  of  pith  or  cork,  which  is  free  to  move  up 
and  down  within  the  tube. 


Fig.     18. — Fedde     Indicator    as     Component     of    Standard 
Sphygmomanometer. 


When  determining  the  systolic  pressure  pay  no 
attention  to  this  indicator,  as  each  impact  of  air  will 
make  the  ball  dance  violently,  but  this  has  no  bearing 
on  the  test.  When  the  pressure  has  reached  the 
systolic  point,  close  the  valve  N,  when  the  ball  will 
begin  to  move  slightly  in  rhythm  with  the  pulse.  This 
motion  gradually  increases,  until  it  reaches  a  maxi- 
mum as  the  level  of  the  mercury  column  gradually 


48  Details  of  Test. 


falls,  when,  quite  suddenly,  its  motion  becomes 
markedly  less.  At  the  moment  of  this  reduced  move- 
ment the  level  of  the  mercury  will  indicate  the  diastolic 
pressure. 

Cautions. — To  obtain  accurate  and  reliable  clinical 
data  with  the  sphygmomanometer,  it  is  important  that 
some  systematic  technic  be  adhered  to,  and  that  all 
observations  not  only  on  the  same  patient,  but  in  all 
cases,  be  made  under  as  nearly  the  same  conditions 
as  possible.  Attention  to  detail  will  eliminate  largely 
the  errors  arising  from  such  factors  as  position  of  the 
patient,  presence  of  fatigue  or  mental  excitement,  arm 
used  for  observation,  etc.  It  is  also  valuable  to  note 
the  apparatus  used,  the  time  of  day,  the  pulse  rate, 
the  sex  and  age  of  the  patient. 

It  is  important  that  the  location  of  the  cuff  should 
be  at  the  heart  level,  otherwise  the  reading  will  be 
affected  by  the  weight  of  gravity  on  a  column  of 
blood,  being  higher  or  lower,  according  to  whether 
the  cuff  is  above  or  below  the  heart  level.  The 
further  the  cuff  is  below  the  heart  level  the  higher 
the  reading. 

Position  of  Patient. — From  the  studies  of  Sandford 
and  others,  as  recorded  on  page  55,  it  will  be  seen 
that  the  position  of  the  patient  is  of  great  importance, 
as  the  systolic  pressure  under  the  same  conditions 
rises  from  5  to  15  mm.,  as  the  posture  of  the  patient 
chances  from  the  standing  to  the  recumbent  posture. 

Continued  constriction  of  the  arm  by  the  cuff  for 
more  than  a  minute  or  two  will  provoke  vaso-motor 
changes  in  the  member,  which  may  cause  a  rise  of 
from  5  to  10  mm.  in  subsequent  readings. 

Another  point  of  importance  in  connection  with  the 


Recording  Observations.  49 

actual  use  of  the  blood-pressure  apparatus  is  that  when 
taking  the  systolic  pressure  the  reading  should  never 
be  made  as  the  pressure  is  being  raised  in  the  cuff, 
but  only  after  the  obstruction  of  the  vessel  is  com- 
plete by  the  air  in  the  cufT  and  while  the  column  is 
returning  by  means  of  the  escape  of  air  through  the 
valve.  Experience  has  shown  that  there  is  a  differ- 
ence of  several  millimeters  between  readings  made  in 
these  two  ways,  and  that  the  reading  taken  at  the 
moment  of  the  return  of  the  first  impulse  at  the  wrist 
is  the  true  systolic  pressure. 

No  single  reading  should  be  accepted  when  it  is 
possible  to  make  more  than  one.  It  is  better  to  see 
the  patient  a  number  of  times  under  varying  condi- 
tions before  deciding  what  his  blood-pressure  is. 

The  following  printed  record  form  has  been  taken 
from  the  Author's  Work  on  Essentials  of  Laboratory 
Diagnosis,  4th  edition,  F.  A.  Davis  Co.,  Philadelphia, 
1912.  This  will  be  found  useful  for  keeping  a  com- 
plete record  of  the  Blood-pressure  Test,  also  the  chart 
as  shown  in  Fig.  19  (page  51)  is  valuable  where  a 
series  of  observations  are  made  upon  one  patient. 
This  chart  is  arranged  to  keep  the  readings  in  graphic 
form,  similar  to  the  usual  temperature  chart. 

Some  observers  prefer  the  graphic  charts  which 
show  the  variation  in  blood-pressure  and  pulse  in  the 
same  manner  as  a  temperature  chart. 

The  accompanying  cut  shows  a  chart  which  has 
been  carefully  prepared  and  which  is  arranged  to 
show  both  systolic  and  diastolic  pressure,  together 
with  pulse  rate,  in  such  a  manner  that  they  do  not 
become  superposed.  These  may  be  obtained  on  the 
market  in  pads  of  25  for  a  nominal  figure  or  directly 
by  writing  to  G.  P.  Pilling  &  Son  Co.,  Philadelphia. 


50 


Clinical  Report  Form. 


BLOOD-PRESSURE  DETERMINATIONS 

Clinical  Report 


Apparatus    \ 

Width  of  Cuff  cm. 

Part  examined, 
Right, 
Left, 
Posture, 
Pulse   Rate, 
Systolic  mm.  Hg.  after  10  bending  movements. 

mm.  Hg. 
Diastolic  mm.   Hg.  after   10  bending  movements. 

mm.   Hg. 
Pulse  Pressure         mm.   Hg.  after  10  bending  movements, 

mm.   Hg. 
Mean  Pressure  mm.  Hg.  after  10  bending  movements, 

mm.  Hg. 

Remarks. 


Time  of  Day,  A.  :\r P.   M. 

Date 

Examined    by 


Graphic  Cii. 


51 


FAUGHT  CHART  I  OR  BLOOD-PRESSURE  RECORDS. 


PULSE.  TEMPERATURE  AND  BLOOD 

PRESSURE  CHART 

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Fig.  19. — Blood-pressure  recording  chart,  about  one-eighth 
actual  size.  Designed  to  record  systolic  pressure,  dias- 
tolic pressure,  pulse  rate  and  temperature. 

Published  by  G.  P.  Pilling  &  Son  Co.,  Phila.,  Pa. 


CHAPTER  IV. 

NORMAL  BLOOD-PRESSURE  AND  ITS 
VARIATIONS. 

Definition  of  NormsJ  Pressure       ....  53 

Average  Normal  Pressure  for  Any  Age  54 

Factors  Affecting  Normal  Average  Blood-Pressure   .  54 

Sex 54 

Physical  Condition 54 

Exercise      .......  54 

Sleep  and  Rest     ......  54 

Posture 55 

Time  of  Day       .        ".         .         .         .         .  57 

Consumption  of   Fluids       .         .         .         .  57 

Age 57 

Altitude  and  Atmospheric  Changes     .         .  57 

Ingestion  of  Food 59 

Consumption  of  Alcohol     ....  59 

Use  of  Tobacco  .....  60 

Extent  of  Permissible  Variation      ....  60 

Determination  of  Abnormal  Pressures    .  61 

Arterial  Hypertension         ....  61 

Arterial  Hypotension  .         .  <       .         .  62 


CHAPTER    IV. 

NORMAL  BLOOD-PRESSURE  AND  THE  CAUSES 
OF  VARIATION. 

When  normal  blood-pressure  is  spoken  of  in 
discussion,  it  is  accepted  to  mean  that  the  pressure  in 
each  individual  case  is  within  the  recognized  normal 
limits  determined  by  clinical  experience.  This  is  not 
and  cannot  be  a  fixed  pressure,  as  the  normal  tem- 
perature is  a  fixed  degree.  This  is  because  blood- 
pressure  at  any  given  moment  is  the  result  of  a  com- 
bination of  variable  factors,  which  must  unite  to  de- 
termine it,  and  because  it  has  been  found  by  experi- 
ence that  blood-pressure  is  regularly  influenced  and 
modified  by  the  age  and  sex  of  the  individual. 

There  are  several  methods  of  arriving  at  an  estima- 
tion of  the  normal  pressure  and  its  variations  in  a 
given  case.  Thus  we  can  adhere  to  a  table  based  on 
a  large  clinical  and  experimental  study.  Such  a 
table,  which  conforms  to  the  accepted  standard,  has 
been  compiled  by  Woley. 

Method  of  Estimating  Normal  Average. — The  normal 
average  systolic  pressure  can  be  readily  determined 
for  all  ages  by  employing  a  formula  devised  by  the 
author  several  years  ago.  This  is  based  on  the  experi- 
mental study  of  many  observers,  and  is  designed  to 

53 


54  Factors  Affecting  Blood-Pressure. 

estimate  the  age  factor  thus :  ''Consider  the  normal 
systolic  blood-pressure  of  a  healthy  adult  male,  age 
20,  to  be  120  mm.  Hg.  .  Then  for  any  two  years  of 
life  over  this  add  1  mm.  Hg.  to  120.  Thus  at  age 
30  blood-pressure  equals  125,  at  age  60  it  equals  140, 
etc." 

The  Sex  Factor  can  be  roughly  reckoned  as 
minus  10,  so  that  all  pressures  as  computed  by  this 
formula  should  have  10  mm.  subtracted  when  estimat- 
ing the  average  normal  pressure  for  women. 

It  is  accepted  that  other  factors  which  are  usually 
part  of  the  daily  life  of  an  individual  will  somewhat 
influence  the  blood-pressure  ;  thus : 

Physically  weak  persons  will  usually  show  a 
slightly  lower  pressure,  often  5  to  10  mm.,  while  the 
MUSCULARLY  DEVELOPED  wiU  havc  a  sHghtly  higher 
average,  about  5  to  10  mm. 

The  pressure  after  Exercise  will  be  found  from 
10  to  20  mm.  above  the  average,  but  will  rapidly 
return  to  normal.  The  same  may  be  said  of  the  first 
hour  after  a  hearty  meal. 

Effects  of  sleep  and  rest  on  Blood-pressure. — Brooks 
and  Corroll  (Arch,  of  Int.  Med.,  August,  1912) 
studied  this  effect  in  68  patients,  showing  average 
systolic  pressures  in  30  with  low  pressure  and  20 
with  abnormally  high  pressure.  The  results  in  the 
general  way  are  illustrated  in  the  cases  with  average 
pressure.  Readings  were  taken  from  1  to  2  hours 
after  the  beginning  of  sleep  and  showed  an  average 
fall  of  24  mm. ;  three  hours  after  waking  in  the  morn- 
ing there  was  still  an  average  depression  of  12  mm. 
In  these  persons  the  pressure  gradually  rose  to  its 
high  level  in  the  afternoon. 


Posture  on  Blood-Pressure.  55 

The  greatest  nocturnal  fall  in  ])rcssure  took  place 
in  cases  having  the  highest  initial  systolic  pressure. 
Disturbance  of  the  patients  during  the  first  sleep 
delays,  but  does  not  necessarily  prevent  the  fall. 
Frequent  interruption,  however,  does  prevent  it. 

The  use  of  hypnotic  doses  of  drugs  to  produce  sleep, 
as  120  grains  of  bromide  of  potassium  or  chloral 
hydrate  up  to  50  grains  each  night,  did  not  increase 
the  degree  or  persistence  of  the  fall.  Physical  rest 
in  general  did  not  appear  to  alter  materially  either 
the  subnormal  or  normal  blood-pressure,  but  the 
authors  were  led  to  believe  that  mental  and  physic 
rest  might  cause  profound  changes  in  pressure  and 
that  these  factors  largely  determine  the  undoubted 
benefit  derived  from  rest  in  cases  of  high  pressure. 

Posture  will  affect  the  reading,  and  its  effect  is 
largely,  if  not  entirely,  due  to  the  effect  of  gravity  and 
the  relation  of  the  arm-band  to  the  chief  volume  of 
blood  in  the  body. 

The  effect  of  change  of  posture  without  active  mus- 
cular exertion  on  arterial  pressure  was  reported  by 
J.  H.  Barach  and  W.  L.  Marks  in  Archives  of  Inter- 
nal Medicine,  May,  1913. 

Without  going  into  the  methods  employed  in 
obtaining  these  conclusions,  it  is  sufficient  to  say  that 
the  mercurial  type  of  instrument  was  used  with  a 
10  cm.  cuff,  that  the  methods  were  carefully  checked 
by  controls  and  that  any  outside  factors  which  might 
influence  the  results  were  eliminated,  as  far  as  pos- 
sible, and  that  all  readings  were  repeated  in  order 
to  eliminate  accidental  error. 


56  Summary  of  Effects. 

The  summary  of  results  is  as  follows : 

1.  When  the  element  of  muscular  effort  has  been 
eliminated,  change  of  bodily  posture  from  the  erect 
to  the  horizontal  will  cause  an  increase  in  the  maxi- 
mum pressure,  a  decrease  in  the  minimum  pressure 
and  an  increase  in  the  pulse  pressure. 

2.  After  five  minutes  in  the  horizontal  posture, 
when  the  subject  is  returned  to  the  erect  posture,  the 
maximum  pressure  will  diminish,  the  minimum  press- 
ure increase  and  the  pulse  pressure  diminish.  It  will 
be  noted  that  in  both  instances  the  pulse  pressure  fol- 
lows the  same  trend  as  the  maximum  pressure. 

3.  Change  of  posture  from  the  erect  to  horizontal 
caused  a  fall  in  the  venous  pressure. 

4.  Change  of  posture  from  the  horizontal  to  erect 
caused  an  increase  of  the  venous  pressure. 

It  will  be  noted  that  the  venous  pressure  follows 
the  same  trend  as  the  minimum  pressure. 

Nearly  all  subjects  of  this  series  responded  in  the 
same  way.  The  most  notable  exception  was  in  the 
"Poor  Muscular  Cases."  These  cases  showed  a  ten- 
dency to  a  reversal  of  the  pressure  curve.  Form 
erect  to  horizontal  caused,  in  more  than  half  of  the 
cases,  a  decrease  of  the  maximum  pressure  and  an 
increase  of  minimum  pressure. 

General  Summary. 

Erect  Horizontal  Erect 

Maximum +             +  — 

Minimum    +             "~  + 

Pulse  pressure  +             +  — 

Venous  pressure  +            —  + 


Age  on  Blood -Pressure.  57 


Time  of  day  has  a  modifying  influence  on  blood- 
pressure,  being  usually  lowest  during  the  early  hours 
of  profound  sleep,  rising  slightly  toward  morning, 
and  rising  more  or  less  rapidly,  depending  on  the 
mental  and  physical  activities  of  the  individual,  as  the 
day  advances.  This  variation  may  reach  as  much  as 
40  mm.  Hg. 

Ingestion  of  large  amounts  of  fluid,  particularly  if 
Alcoholic,  will  cause  a  moderate  and  brief  rise. 

Pain  and  anxiety  are  often  a  cause  for  a  sharp  and 
short  rise. 

Age. — The  following  table  is  taken  from  L.  Gor- 
don, who  has  made  extensive  study  of  the  relation  of 
age  in  normal  children  to  blood-pressure. 

mm. 

Under  one  year   71 

One  year   Th 

Two  years 79.3 

Three  years 81 

Four  years    83 

Five   years    86.5 

Six  years  88.5 

Seven  years 85.0 

Eight  years   93 

Nine  years    100 

Ten  years    95 

Eleven  years   104 

Twelve  years    105 

Effects  of  Altitude  and  Atmospheric  Changes  on  Blood- 
Pressure  and  Pulse  Rate. — Hoobler  and  Pomeroy,  in  a 
review  of  literature  combined  with  their  own  obser- 
vations on  the  effect  of  Barometric  Pressure  on 
blood-pressure,   state   that   ''the    result   of   nearly   all 


58  The  Climatologic  Effect. 

experimental  data  shows  that  diminished  barometric 
pressure  lowers  blood-pressure."  C.  F.  Gardner  has 
shown  that  a  person  going  from  an  elevation  of  6000 
feet  to  one  of  14,000  feet  suffers  a  fall  in  blood-pres- 
sure and  a  rise  in  pulse  rate.  The  results  of  Schnei- 
der and  Hedblom  are  the  same.  They  state  also  that 
the  diastolic  pressure  tends  to  be  lower  by  reduction 
in  barometric  pressure.  That  the  fall  in  systolic  pres- 
sure was  slightly  greater  and  more  certain  to  occur 
than  the  fall  in  diastolic  pressure.  This  effect  be- 
comes less  marked  as  the  subject  becomes  accustomed 
to  the  change.  The  change  usually  amounts  to  from 
3  to  10  mm. ;  occasionally  as  much  as  a  20  mm.  rise 
has  been  noticed. 

In  tuberculous  subjects  with  hypotension,  high  alti- 
tude (6000  feet)  causes  a  rise  in  pressure  (Peters, 
Arch,  of  Int.  Med.,  Aug.,  1908). 

Colis  and  Pembrey  have  studied  the  important  fac- 
tors of  Relative  Humidity  in  the  atmosphere  to 
blood-pressure,  and  have  found,  by  studies  made  in 
England,  that  when  the  Actual  Humidity  was 
greatly  increased,  a  rise  in  pulse  rate  of  30  or  more 
beats  per  minute  not  infrequently  occurred,  and  there 
was  also  an  increase  in  respiratory  rate  of  from  18  to 
29.  The  same  results  were  noted  when  the  actual 
humidity  was  increased. 

P.  P.  Aminet  examined  a  large  number  of  healthy 
children  of  from  7  to  15  years  of  age  in  an  effort  to 
determine  the  effect  of  outdoor  life  on  pulse  and 
blood-pressure.  He  found  that  almost  uniformly 
there  was  an  increase  in  blood-pressure  and  in  pulse 
rate.  The  pressure  elevation  amounted  to  as  much 
with  some  cases  as  at  30  mm.  Hg.     Children  living  in 


Alimentary  Hypertension.  59 

good  surroundings  have  a  generally  higher  blood-pres- 
sure than  those  in  poorer  environments.  The  same 
condition  was  noted  by  Hoobler  in  children  suffering 
from  tuberculosis  or  pneumonia. 

Starling  has  studied  the  ejfect  of  wind-pressure 
upon  the  systolic  blood-pressure,  which  has  a  very 
important  bearing  upon  the  effect  of  this  condition 
upon  cardiac  cases.  He  found  that  wind-pressure  has 
a  profound  influence  in  raising  pulse  rate.  The  same 
may  be  said  of  the  effect  of  wind-pressure  upon  the 
blood-pressure. 

Eating. — The  blood-pressure  normally  rises  from  10 
to  15  mm.  shortly  after  an  ordinary  meal,  gradually 
falling  toward  the  original  level  after  an  hour  or  more. 
The  size  of  the  meal  is  thought  by  some  observers  to 
affect  the  degree  of  elevation,  being  greatest  after 
heavy  meals  which  contain  much  proteid. 

It  is  well  recognized  that  certain  changes  in  the 
circulatory  system  originate  from  disturbances  in  the 
digestive  tract.  These  are  usually  seen  in  a  slight 
increase  in  blood-pressure,  due  to  the  reflex  from  the 
splanchnic  area  affecting  the  muscular  walls  of  the 
arteries.  This  may  be  considered  normal  to  a  certain 
degree,  but  it  becomes  pathologic  where  we  find  this 
elevation  to  be  excessive  and  prolonged. 

Alimentary  hypertension  is  the  result,  therefore,  of 
a  normal  abdomino-arterial  reflex,  made  excessive  by 
an  over-abundance  of  food  or  an  incomplete  elimina- 
tion of  toxic  substances.  This  continued  hypertension 
is  often  the  first  link  in  the  chain  leading  to  arterio- 
sclerosis, contracted  kidneys  and  apoplexy. 

Drinking. — Excessive  ingestion  of  water  causes  a 
brief  rise  of  blood-pressure,  amounting  to  about  5  to 


60  Tobacco  on  Blood- Pressure. 

10  mm.,  although  the  habitual  use  of  ordinary  amounts 
need  hardly  be  considered  in  any  blood-pressure  esti- 
mation. Large  amounts  of  beer  may  be  the  cause  of 
a  sharp  rise,  which,  when  repeatedly  recurring,  as  in 
habitual  beer  drinkers,  may  become  the  cause  of  a 
permanent  hypertension,  which  may  finally  result  in 
arteriosclerosis  and  chronic  nephritis.  Strong  alco- 
holic drinks  cause  a  primary  rise  from  heart  stimu- 
lation, followed  by  a  secondary  fall  when  vasodilata- 
tion occurs. 

Smoking. — Smoking  usually  causes  an  elevation  in 
blood-pressure,  with  the  apparent  paradox  that  many 
habitual  smokers  have  a  subnormal  blood-pressure. 
The  usual  effect  of  one  or  two  cigars,  or  its  equiva- 
lent in  other  forms,  in  those  accustomed  to  the  use  of 
the  drug  is  a  sedative  action  and  a  slight  lowering  of 
blood-pressure,  while  excessive  smoking,  during  a 
short  period  of  time,  causes  a  rise  of  from  5  to  25  mm. 

Bruce  Miller  and  Hooker,  after  extensive  study, 
arrive  at  the  conclusion  that  smoking  is  an  etiologic 
factor  in  arteriosclerosis,  at  least  in  so  far  as  the 
effect  of  circulating  toxic  substances  affect  the  enlarg- 
ment  of  the  vessel  walls. 

Permissible  Variations. — From  the  foregoing  it  would 
seem  that  any  study  of  blood-pressure  must  have  its 
value  greatly  reduced  by  so  many  modifying  factors, 
but  careful  thought  will  show  that  these  at  most  cause 
only  slight  variation,  which  need  not  obscure  the 
issue.  Experience  will  teach  the  observer  to  uncon- 
sciously include  these  factors  in  practice  and  enable 
him  to  arrive  at  the  correct  value  of  his  findings  by 
aid  of  them. 


;iAL  HypertknsiOn.  61 


Determination  of  Pathologic  Blood- Pressure 

Abnormal  blood-pressure  may  be  either  a1)ove  or  below 
the  normal  level,  as  compared  to  the  normal  average 
pressure  and  its  variations.  Blood-pressure  should 
only  be  designated  abnormal  after  careful  study  and 
repeated  tests,  unless  the  change  is  so  marked  as  to 
be  beyond  question. 

A  single  reading  slightly  above  or  below  the  normal 
boundaries  may  be  occasioned  by  some  accidental  or 
peculiar  incident,  and  should  therefore  not  be  taken 
too  seriously  and  should  never  be  assigned  to  an  im- 
portant role  in  diagnosis  until  its  persistence  has  been 
demonstrated  on  at  least  two  occasions. 

Neither  should  one  expect  to  find  the  same  pressure, 
in  any  case,  at  all  times.  Never  lose  sight  of  the  pos- 
sible causes  of  normal  variation.  These  normal  varia- 
tions may  occur  in  a  very  short  space  of  time,  and 
should  not,  as  in  at  least  one  instance  known  to  the 
author,  condemn  the  instrument,  showing  such  varia- 
tion, as  inaccurate.  Remember  also  that  your  unfa- 
miliarity  with  a  new  type  of  instrument  may  cause 
you  to  neglect  some  detail  which  will  invalidate  your 
results. 

Study  your  instrument,  read  your  instructions  and 
he  sure  of  our  technic. 

Arterial  Hypertension. — For  a  proper  understanding 
of  the  treatment  of  the  various  conditions  associated 
with  which  the  arterial  pressure  is  above  normal,  it 
must  primarily  be  recognized  that  if  the  pressure  is 
high  there  must  be  some  underlying  cause  for  the 
abnormality.    Such  cases  can,  as  a  rule,  be  divided  into 


62  Causes  of  High  Pressure. 

three  groups :  mechanical,  nervous  and  toxic.  The 
most  common  mechanical  cause  is  arteriosclerosis, 
and  yet  there  may  be  pipe-stem  arteries  with  normal 
pressure.  The  reflex  nerve  irritation  of  a  peritonitis 
or  a  fright  may  cause  a  sharp  rise  in  pulse  tension, 
but  in  shock  the  blood-pressure  falls.  The  cause  of 
hypertension,  which  is  probably  the  most  widespread 
and  the  most  frequent,  is  intoxication.  It  is  generally 
considered  that  it  is  the  irritation  from  poisons 
retained  by  the  kidneys  and  not  the  mechanical 
obstruction,  which  sends  the  blood-pressure  up  in 
nephritis. 

Continuous  high  pressure  is  seen  in  certain  forms 
of  NEPHRITIS.  Thus,  in  primary  acute  Bright's  disease 
and  in  nephritis  secondary  to  scarlet  fever  there  is 
practically  always  a  marked  rise  in  arterial  pressure. 
A  rise  amounting  to  more  than  50  mm.  Hg.  has  been 
observed  within  48  hours  of  the  onset  of  an  acute 
nephritis.  Elevated  pressure  is  also  found  in  begin- 
ning ARTERIOSCLEROSIS  of  the  first  part  of  the  aorta 
and  of  the  splanchnic  vessels. 

In  dealing  with  the  elevation  of  pressure,  which  is 
the  result  of  the  action  of  drugs  or  of  toxic  agents, 
it  is  important  to  bear  in  mind  that  the  amount  of  the 
substance  and  its  concentration,  its  potency  as  well  as 
the  duration  of  its  action  will  determine  the  amount 
of  elevation,  the  duration  and  the  permanence  of  the 
effect. 

Arterial  Hjrpotension. — This  term  is  applied  to  cases 
presenting  a  more  or  less  continuous  blood-pressure 
below  the  normal  estimated  pressure.  A  pathologic 
depression  in  blood-pressure  may  be  caused  by  the 
depressing   influence   of   circulating   toxins   acting 


Extreme  Low  Pressures.  63 

either  upon  the  heart  hlood-vesscls  or  controHing  ner- 
vous mechanism  or  to  sudden  withdrawal  of  a  large 
volume  of  blood  from  the  circulation,  as  in  iirmor- 
RiiAGE,  after  venesection,  copious  diaphoresis,  diar- 
rhea, or  in  shock. 

The  lowest  blood-pressure  compatible  with  life  has 
been  reported  by  Neu  to  be  from  40  to  45  millimeters 
of  mercury,  and  this  only  occurred  with  subnormal 
temperature  in  the  moribund  state.  He  has  seen  re- 
covery after  a  fall  in  pressure  as  low  as  50  milli- 
meters. 

In  general,  it  may  be  said  that  lowered  blood-pres- 
sure is  of  little  significance  except  after  hemorrhage 
or  during  surgical  shock.  Here  the  great  and  sudden 
reduction  in  pressure  may  be  sufficient  to  immediately 
endanger  life. 

It  is  noted  that  a  moderate  and  progressive  fall  in 
pressure  occurs  in  most  progressive  and  prolonged 
fevers,  as  in  typhoid  fever.  When  due  to  such  a 
cause,  the  depression  is  rapidly  overcome  and  disap- 
pears as  convalescence  is  established. 

Widespread  dilatation  of  the  vessels  and  conse- 
quent lowering  of  blood-pressure  has  been  noted  in 
the  last  stages  of  arteriosclerosis. 

Arterial  dilatation  and  lowering  of  blood-pressure 
may  result  from  general  loss  of  arterial  tone.  Thus, 
if  the  splanchnic  vessels  become  widely  dilated  and 
filled  with  blood,  the  other  arteries  are  insufficiently 
filled  (there  is  insufficient  blood  in  the  body  to  prop- 
erly fill  the  arteries  if  they  are  all  widely  dilated) 
(see  page  85),  and  the  pulse  becomes  soft,  the  tem- 
perature falls  and  syncope  finally  ensues. 


CHAPTER  V. 
PRACTICAL  APPLICATION  OF  CLINICAL  DATA. 

I 

CONDITIONS    ACCOMPANIED    BY    HIGH 
PRESSURE. 

II 

CONDITIONS    ACCOMPANIED    BY    BUT    SLIGHT 

PRESSURE  CHANGE. 

Ill 
CONDITIONS  ACCOMPANIED  BY  LOW 

PRESSURE. 

I 

High  Blood-Pressure  as  a  Symptom       ...         65 

Arteriosclerosis      .......         66 

Blood-Pressure  Findings  in        ...         67 

Angina   Pectoris 68 

Blood-Pressure  Findings  in         .         .         .  68 

Acute  Nephritis  .         .         .         .         .  68 

Effect  on  Blood-Pressure    ....  68 

In  Children 69 

Chronic   Nephritis 69 

Blood-Pressure  Changes  in         ...  70 

Signs  of  Kidney  Failure     ....  70 

Uremia 70 

Chronic  Parenchymatous  Nephritis  70 

Valvular  Disease  of  the  Heart  71 

Aortic  Regurgitation  .         .         .         :         72 

Blood-Pressure  Changes  in  .         .         .         72 


Disease  of  the  Heart  Muscle  . 

Acute  Endocarditis 
Chronic  Myocarditis 

Blood-Pressure  Changes  in 

Functional  Tests 
Schapiro's  Test 
Graupner's  Test 
Effect  of  Altitude  in  Heart  Cases 

Eclampsia 

Cerebral    Hemorrhage    . 

Apoplexy  and  Cerebral  Thrombosis 

Migrain         .... 

Chronic  Lead  Poisoning 

Disease  of  the  Eye 

Arteriosclerosis 
Ocular  Hemorrhage    . 

Inasphyxia    .... 

Syphilis  of  the  Heart  and  Blood-Vessels 


II 


Asthma 

Cardiac  Asthma 

Chronic   Bronchitis 

Neuralgia 

Neurasthenia 

Obesity 

Effect  of  Edema 

Acute  Insanity 
Rheumatism 


Exophthalmic  Goiter 

Infectious  Diseases 

Typhoid  Fever    . 
Pneumonia 

Injection  of  Salvarsan 

Epilepsy 


III 

Varieties  of  Hypotension 

Terminal  Hypotension 
Essential  Hypotension 
Primary  Hypotension 
Relative  Hypotension 

Diabetes       .... 

Cardiac  Dilatation 

Shock  and  Collapse 

Hemorrhage 

External  Hemorrhage 
Internal  Hemorrhage 

Cerebral   Embolism 

Jaundice 

Pulmonary  Tuberculosis 

Effect  of  Altitude  on  Pressure 

Anemia 

Chlorosis 

Cholera 

Alcoholic   Delirium 


CHAPTER  V. 

PRACTICAL  APPLICATION  OF  CLINICAL  DATA 
IN   EVERY-DAY  PRACTICE. 

As  already  stated,  the  relation  of  blood-pressure  in 
disease,  compared  to  the  estimated  normal  in  health, 
may  be  variable  (slightly  above  or  below),  may  tend 
to  hypotension  or  may  show  high  pressure.  The  ar- 
rangement of  the  various  conditions  treated  in  the 
following  pages  is  entirely  arbitrary,  being  based  on 
a  plan  which  renders  the  material  most  readily  acces- 
sible and  easily  obtainable  for    immediate  reference. 

High  Blood-Pressure  Is  a  Symptom^  Not  a  Disease. — 
It  is  present  in  a  number  of  common  pathologic  con- 
ditions, and  when  found,  aids  greatly  in  explaining 
certain  phenomena  connected  with  the  heart,  blood- 
vessels and  kidneys.  The  state  of  the  blood-pressure 
often  furnishes  the  one  important  clue  which  leads  to 
correct  diagnosis  or  directs  the  attention  to  an  alto- 
gether unsuspected  complication. 

For  example,  a  case  of  pneumonia  is  related  in 
which  all  was  progressing  satisfactorily  until  one  day 
the  patient  did  not  seem  to  be  as  well  as  the  state  of 
his  disease  would  warrant.  A  blood-pressure  test, 
made  by  a  consultant  who  had  been  called,  demon- 
strated an  abnormally  high  blood-pressure.  The  urine 
was  then  examined  and  evidence  sufficient  to  establish 
the  presence  of  a  complicating  nephritis  was  found. 

65 


(^  Arteriosclerosis. 


At  the  present  time  certain  diseased  conditions  are 
well  recognized  as  being  productive  of  or  usually  ac- 
companied by  an  elevation  in  blood-pressure.  The 
two  almost  classical  high  blood-pressure  conditions 
are  arteriosclerosis  and  acute  and  chronic  nephritis. 
Other  conditions  in  which  a  high  pressure  is  often 
found  are  chronic  myocarditis,  the  complications  of 
arteriosclerosis,  as  angina  pectoris  and  apoplexy.  Also 
uremia,  the  toxemia  of  pregnancy,  lead  poisoning, 
peritonitis  and  cerebrospinal  meningitis. 

Conditions  in  Which  High   Blood-Pressure  is  a 
Prominent  Symptom. 

Arteriosclerosis,  as  the  term  is  here  employed, 
implies  a  condition  of  generalized  chronic  hyperplastic 
involvement  of  the  coats  of  the  arteries.  In  this  con- 
dition we  find  a  permanently  elevated  blood-pressure, 
the  degree  of  which  is  dependent  upon  the  extent  of 
the  involvement  present.  The  wider  the  extent  and 
the  greater  rigidity  of  the  vessels  the  higher  will 
the  systolic  pressure  be.  This  pressure  rtiay  reach 
300  mm.  The  average  case  will  be  found  to  run  in 
the  neighborhood  of  200  mm.  Owing  to  the  lack  of 
elasticity,  the  mechanics  of  the  circulation  are  so 
deranged  that  the  diastolic  pressure  will  be  found 
disproportionately  low,  with  corresponding  greater 
increase  in  pulse  pressure.  It  is  not  uncommon  to  find 
a  pulse  pressure  of  100  or  miore.  The  reduction  in 
the  ratio  of  pulse  pressure  to  systolic  pressure,  under 
treatment,  is  a  valuable  sign.  It  must  be  remembered, 
however,  as  has  been  pointed  out  by  Rudolph,  that 
the   blood-pressure   in   arteriosclerosis   is   not   always 


Causes  of  Artkriosclekosis.  67 

high,  especially  when  the  arterial  involvement  is 
localized,  as  in  the  superficial  vessels,  also  that  very 
high  blood-pressnre  may  be  net  as  a  result  of  arte- 
riosclerosis, in  the  presence  of  apparently  soft  super- 
ficial vessels,  when  the  larger  trunks,  such  as  the 
splanchnic  area,  is  affected. 

Sir  Clifford  Albutt  divided  the  cases  of  high  pres- 
sure related  to  arterial  changes  into  three  classes : 

First — Hypertension  cases. 

Second — Those  of  toxic  or  infective  origin. 

Third — Involutionary  or  true  sclerotic  cases. 

In  the  first  class  the  elevated  blood-pressure  pro- 
ceeds and  produces  the  arterial  change,  while  in  the 
third  the  pressure  is  the  direct  result  of  the  disease. 

As  a  rule,  the  degree  of  elevation  in  pressure  will 
indicate  the  extent  of  arteriosclerotic  involvement, 
the  presence  of  a  complicating  nephritis,  myocarditis 
or  an  aortic  regurgitation  will  tend  to  further  elevate 
the  blood-pressure.  The  terminal  stage  of  a  long- 
standing arteriosclerosis,  even  when  complicated  by 
other  conditions  causing  high-blood  pressure,  is  usual- 
ly marked  by  a  falling  and  finally  a  subnormal  blood- 
pressure. 

The  blood-pressure  test  in  cases  of  arteriosclerosis, 
besides  being  of  great  value  in  effecting  the  proper 
diagnosis,  is  also  of  marked  assistance  in  following 
the  effect  of  treatment  and  in  forecasting  the  future. 
But  of  greater  value  even  than  the  systolic  pressure 
is  the  diastolic,  which  should  be  estimated  in  order  to 
determine  the  pulse  pressure,  which  is  the  truest  indi- 
cation of  the  amount  and  severity  of  heart  overwork, 
which,  after  all,  is  the  determining  factor  in  the  case. 


68  Angina  Pectoris — Acute  Nephritis. 

Angina  Pectoris. — This  is  usually  a  syndrome,  de- 
veloping in  the  course  of  a  case  of  general  arterio- 
sclerosis, and  denotes  involvement  of  the  coronary 
arteries  in  the  arteriosclerotic  process.  The  blood- 
pressure  rises  just  before  and  remains  high  during  the 
paroxysm  of  pain,  usually  subsiding  shortly  there- 
after. The  rise  may  amount  to  50  mm.,  and  there 
may  be  little  or  no  elevation  in  blood-pressure  during 
the  interval.  The  reduction  of  high  blood-pressure 
in  those  with  a  tendency  to  angina  is  often  most  suc- 
cessful in  preventing  subsequent  attacks. 

The  blood-pressure  test  sometimes  serves  as  a  val- 
uable aid  in  differentiating  true  angina  from  those 
conditions  best  termed  anginoid,  which  are  so  often 
met  and  which  frequently  cause  the  physician  much 
trouble  and  embarrassment  in  estimating  their  true 
significance.  It  is  believed  by  Janeway  and  others 
that,  given  a  case  presenting  the  symptom  complex  of 
angina,  in  which  the  blood-pressure  is  continually  ab- 
normally high,  it  will  probably  be  one  of  true  angina; 
while  unfortunately  the  converse  is  not  true,  as  cases 
of  demonstrated  true  angina  have  been  met  in  which 
the  pulse  is  small,  easily  compressible  and  the  tension 
low. 

Acute  Nephritis. — A  sharp  rise  in  blood-pressure  is 
usually  the  first  sign  of  the  onset  of  an  acute  nephritis. 
This  complication,  developing  in  the  course  of  an 
acute  infection,  may  be  discovered  by  a  routine  study 
of  the  blood-pressure,  where  the  rise  may  antedate 
the  development  of  the  usual  signs,  including  altera- 
tions in  the  urine  by  as  much  as  24  hours.  This  fact 
should  be  a  most  emphatic  indication  of  the  value  and 
importance  of  daily  blood-pressure  readings  during 
the  course  of  all  infections,  particularly  scarlet  fever. 


Chronic  Nephritis.  69 


Acute  Nephritis  in  Children. — Lennox  Gordon  reports 
9  cases,  in  all  of  which  the  blood-pressure  was  raised, 
in  some  cases  to  a  very  high  level,  and  in  them  this 
was  of  very  marked  diagnostic  value.  He  believes 
that  by  means  of  the  sphygmomanometer  only  could 
the  change  in  blood-pressure  in  children  be  ascertained 
to  any  degree  of  certainty. 

Chronic  Nephritis. — ^A  gradually  developing  chronic 
nephritis  is  shown  by  a  gradually  rising  blood-pres- 
sure, accom.panied  by  the  usual  alterations  found  in 
the  urine.  A  high  blood-pressure  reading,  of  more 
than  200  mm.  found  during  the  examination  of  any 
patient  should  place  one  on  guard  and  start  a  careful 
examination  for  other  signs  of  this  condition. 

The  blood-pressure  in  chronic  nephritis  is  persist- 
ently elevated,  and  may  be  extremely  high.  Pressures 
of  over  300  mm.  have  been  reported.  A  sudden 
further  rise  in  pressure  occurring  during  the  course 
of  a  chronic  nephritis  is  often  a  most  valuable  warn- 
ing, as  a  sign  indicative  of  an  impending  uremic 
attack.  This  rise,  if  noted  early,  furnishes  the  basis 
for  immediate  action,  to  control  the  pressure  by  pow- 
erful eliminative  measures  in  order  to  avert,  if  pos- 
sible, the  uremic  attack.  Such  treatment  if  often  very 
successful. 

J.  Fischer,  in  the  Duch.  Arch.  f.  klin.  Med.,  1913, 
after  a  study  of  550  patients  running  a  continuous 
high  blood-pressure,  emphasizes  the  importance  of 
being  on  the  lookout  for  permanent  kidney  lesions  in 
patients  even  with  a  moderately  high  pressure,  as  in 
62%  of  his  series  with  pressure  above  140  there  were 
signs  of  permanent  kidney  lesions,  while  80%  had 
chronic  kidney   change,   and   in   some   of   these   there 


70  Uremia. 


was  no  clinical  evidence  of  kidney  trouble,  excepting 
continuous  high  blood-pressure. 

A  study  of  blood-pressure  in  cases  showing  tran- 
sient or  persistent  traces  of  albumen  in  the  urine  will 
often  serve  to  demonstrate  the  cause  and  seriousness 
of  this  condition,  because  it  is  well  known  that  high 
blood-pressure  is  always  an  accompaniment  of  chronic 
nephritis,  and  also  because  it  is  believed  that  a  normal 
blood-pressure,  even  with  albumen  in  the  urine,  places 
the  albumen  in  a  class  with  minor  and  not  serious 
affections.  Unexplained  persistent  high  blood-pres- 
sure, even  when  albumen  cannot  be  demonstrated  in 
the  urine,  furnishes  ample  grounds  for  strongly  sus- 
pecting chronic  changes  in  the  kidneys. 

After  a  long  or  short  period  of  sustained  high  pres- 
sure in  chronic  nephritis,  the  pressure  will  begin  to 
fall,  and  after  a  long  period  of  time  fail  to  raise  to  its 
highest  level.  Experience  teaches  that  this  is  a  danger 
signal  that  the  reserve  of  the  heart  and  circulation 
has  been  exhausted  and  that  a  further  fall  may  be 
expected,  and  that,  sooner  or  later,  this  will  result  in 
retarded  kidney  activity  and  all  that  this   implies. 

Chronic  Parenchymatous  Nephritis. — The  few  avail- 
able reports  on  blood-pressure  in  this  disease  fail  to 
show"  that  a  high  blood-pressure  is  an  accompaniment 
of  it  or  that  the  blood-pressure  bears  any  relation  to 
the  duration  or  severity  of  the  kidney  inflammation. 

Uremia. — This  often  fatal  complication  of  nephritis 
is  accompanied  by  a  sudden  and  often  sharp  rise  in 
an  already  greatly  elevated  blood-pressure,  or  else  an 
already  high  pressure  begins  to  mount  upward  to  a 
dangerously  high  level.  These  changes  in  blood-pres- 
sure may,  by  careful  observation  with  the  sphygmo- 


Blood-Pressukk  in  Valvular  Dlsease.  71 

manometer,  l)e  noted  suflicicntly  early  to  allow  time 
for  the  institution  of  preventive  measures,  directed 
toward  the  relief  of  toxemia,  by  increasinj^  elimina- 
tion. The  l)lood-])rcssure  durin<(  an  uremic  attack 
may  be  far  above  v300  mm.  Actually  how  high  has 
not  been  recorded,  because  before  the  development 
of  the  Faught  Clinical  Sphygmomanometer  no  instru- 
ment was  capable  of  recording  pressures  above  300 
mm. 

In  patients  who  are  seen  in  emergency  and  are 
found  profoundly  unconscious,  the  sphygmomanomet- 
er will  often  be  the  means  of  separating  the  coma  of 
uremia  with  high  blood-pressure  from  coma  of  other 
origin. 

In  Valvular  Lesions. — In  the  study  of  the  valvular 
disease  of  the  heart  the  results  do  not  seem  to  have 
special  bearing  upon  the  primary  condition  (defective 
valve)  except  in  cases  of  aortic  regurgitation.  This 
is  in  part  due  to  the  usual  complicated  nature  of  the 
condition,  which  often  includes  arterial  and  myocar- 
dial changes  and  involvement  of  the  kidneys. 

The  chief  value  of  the  sphygmomanometer  in  the 
study  of  heart  conditions  applies  to  the  condition  of 
the  myocardium,  to  a  demonstration  of  the  etTect  of 
therapeutic  measures  and  as  a  guide  in  prognosis  and 
in  the  general  management  of  cases.  With  it  we  are 
able  to  determine  with  considerable  accuracy  the  bene- 
fit derived  from  the  drugs  and  other  measures  em- 
ployed. In  this  we  may  guard  against  insufficient  or 
improper  treatment  and  also  against  the  over-use  of 
these  same  measures  by  demonstrating  the  therapeuti- 
cally efficient  dose  and  the  proper  interval  of  its  exhi- 
bition. 


72  Aortic  Regurgitation, 

Aortic  Regurgitation. — The  blood-pressure  test  may 
be  sufficient  to  establish  a  diagnosis  in  pure  aortic  re- 
gurgitation, the  great  pulse  pressure  occurring  in  this 
condition  being  almost  pathognomonic.  Referring  to 
the  physics  of  the  circulation,  we  find  that  in  aortic 
regurgitation  the  left  venticle  is  called  upon  to  deliver 
an  abnormally  large  volume  of  blood  into  the  aorta  to 
supply  the  demands  of  the  circulation.  This  is  because 
the  heart  is  required  not  only  to  furnish  sufficient 
blood  for  the  needs  of  the  body,  but  must  also  inject 
into  the  aorta  at  each  systole  enough  surplus  to  com- 
pensate for  the  regurgitation  of  a  large  volume  of 
blood  into  the  left  ventricle  during  diastole.  The 
natural  result  of  the  sudden  injection  of  this  large 
amount  of  blood  into  the  arterial  system  will  be  to 
cause  a  sudden  and  great  rise  in  systolic  blood-pres- 
sure (immediately  succeeding  systole  the  blood  dis- 
perses in  two  directions,  forward  through  the  capil- 
laries and  backward  into  the  ventricle,  producing  the 
phenomenon  of  the  water-hammer  pulse).  Thus  the 
pressure  rapidly  falls  and  the  diastolic  pressure  is 
abnormally   low.      The    combined   result    of    this 

HIGH     SYSTOLIC    AND     LOW     DIASTOLIC     PRESSURE     IS     A 

GREAT  PULSE  PRESSURE.  This  may  amount  to  100  mm. 
or  more. 

In  the  presence  of  moderate  or  high-grade  gener- 
alized arteriosclerosis,  this  phenomenon  is  further  ac- 
centuated because  the  lack  of  normal  elasticity  in  the 
arterial  system  tends  to  reduce  the  diastolic  pressure 
to  zero. 

Occasionally,  in  cases  of  mitral  stenosis,  the  blood- 
pressure   may  tend   toward   a   low   level,   but  this   is 


Myocardial   Disease.  7?) 

usually  more  than  compensated  for  l)y  the  accompany- 
ing changes  in  the  heart  muscle  and  larger  arteries. 

Acute  Endocarditis. — In  a  few  cases  of  acute  endo- 
carditis that  have  been  reported,  it  has  been  found 
that  the  endo-cardial  condition  itself  has  little,  if  any, 
efifect  on  systolic  blood-pressure. 

Myorcardial  Degeneration. — Many  cases  of  chronic 
myocarditis  have  sufficiently  marked  signs  to  be  easy 
of  diagnosis ;  in  other  cases  of  the  cardiovascular 
renal  type  diagnosis  may  be  extremely  difficult.  Here 
it  is  most  important  that  the  general  practitioner 
should  be  able  to  recognize  these  changes  sufficiently 
early  to  be  able  to  institute  treatment  with  good 
chance  of  arresting  the  progress  of  the  disease  indefi- 
nitely or  as  long  as  the  patient  adheres  to  his  new 
regime.  These  cases  usually  occur  in  middle  life,  and 
may  be  far  advanced  before  discovered,  as  they  often 
are,  accidentally,  in  the  course  of  examinations  for 
life  insurance.  The  difficulty  of  correctly  estimating 
them  is  great,  for,  while  we  may  be  morally  certain 
of  the  existence  of  heart  weakness,  we  may  not  be 
able  to  prove  the  existence  of  myocarditis,  and  often 
erroneously  class  them  as  nervous  or  functional. 

In  the  physical  examination  the  state  of  the  super- 
ficial vessels,  together  with  the  pulse  rate  and  particu- 
larly the  reaction  of  the  heart  to  posture  and  exercise 
as  determined  by  the  sphygmomanometer,  is  all-im- 
portant. This  latter  may  be  determined  by  the  fol- 
lowing tests : 

Functional  Tests. — Moderate  exertion  raises  pressure 
in  normal  hearts,  and  this  rise  is  sustained  during  it 
if  not  unduly  severe  or  prolonged.  In  weakened 
heart  muscles    from   any   cause   a   primary   rise   may 


74  Functional  TEsts. 


occur,  but  is  quickly  followed  by  a  fall;  in  the  worst 
a  fall  occurs  from  the  first 

Schapiro's  Test. — This  is  based  upon  the  alteration 
in  pulse  rate  occurring  in  normal  individuals  on 
change  of  posture  from  the  standing  to  the  recum- 
bent. Normally  the  number  of  pulse  beats  per  minute 
is  from  7  to  10  less  in  the  recumbent  position;  but 
when  chronic  myocarditis  develops,  this  difference 
tends  to  disappear,  so  that  in  seriously  weakened 
hearts  the  pulse  may  be  as  rapid  in  the  recumbent  as 
in  the  sitting  posture. 

Graupner's  Test. — This  is  based  upon  the  physiologic 
fact  that  a  given  amount  of  exercise,  such  as  ten  bend- 
ing movements  or  running  up  a  flight  of  stairs,  causes 
an  acceleration  in  the  pulse  rate  and  an  elevation  in 
blood-pressure.  But  the  latter  does  not  appear  coin- 
cidently  with  the  former;  or  if,  as  in  some  cases,  the 
pressure  does  rise  first,  it  fails  to  rise  again  after  the 
pulse  has  returned  to  normal.  It  is  this  secondary 
rise  which  indicates  a  good  heart  muscle.  A  not  too 
seriously  affected  heart  may  show  a  rise  in  blood- 
pressure  immediately  after  the  exertion,  but  with  the 
slowing  of  the  pulse  the  pressure  will  be  found  to 
have  fallen  to  a  level  lower  than  before  the  experi- 
ment. The  sphygmomanometer  is  required  for  an 
accurate  demonstration  of  these  changes  in  pressure, 
which  may  be  recorded  in  definite  units  of  measure 
for  future  reference  and  comparison. 

It  is  not  advisable  to  apply  this  test  to  pa- 
tients WITH  excessively  HIGH  BLOOD-PRESSURE,  IN 
THOSE    OF    APOPLECTIC    TENDENCY    OR    IN    THOSE    WITH 

HIGH-GRADE  ARTERIOSCLEROSIS.  The  tcst  is  uusafc  in 
those  with  a  systolic  pressure  of  200  millimeters  or 


Altitude  on  Heart  Cases.  75 

over.  In  such  cases  tliere  is  danger  of  ocular  or 
cerebral  hemorrhage  or  acute  dilatation  of  heart. 

The  test  will  be  difficult,  if  not  impossible,  of  appli- 
cation in  women  unless  all  tight  clothing  is  removed. 

Valvular  disease  is  not  necessarily  a  contraindica- 
tion to  this  test,  as  the  condition  of  the  myocardium 
seems  to  be  the  only  important  factor,  except  in  aortic 
regurgitation  with  high  pressure,  so  that  the  presence 
of  valvular  lesions  need  not  detract  from  the  value 
of  the  information  obtained  by  this  test. 

The  Effect  of  Altitude  on  Cardiac  Cases. — It  is  import- 
ant to  consider  the  condition  of  the  patient  in  refer- 
ence to  the  circulation  before  advocating  residence  in 
high  altitudes.  In  young  convalescents,  in  the  absence 
of  organic  heart  affections,  even  in  the  presence  of 
the  moycardial  weakness  due  to  recent  acute  or 
chronic  infections,  moderately  high  altitudes  are 
usually  beneficial. 

In  the  arteriosclerotic  without  valvular  lesions,  the 
cardiac  reserve  is  often  much  exhausted,  and  there- 
fore sudden  changes  in  altitude  may  result  in  serious 
consequences  through  added  sudden  strain  on  the 
circulation,  due  to  changes  in  peripheral  resistance. 
High  altitudes  may  be  extremely  dangerous.  In  the 
true  cardiac  case  with  organic  lesion,  high  altitudes 
are  often  dangerous  because,  even  when  compensa- 
tion is  fairly  well  established,  the  balance  in  favor  of 
the  heart  is  very  slight,  and  here  again  the  changes 
in  circulatory  equilibrium,  by  causing  slight  increased 
strain,  may  again  produce  decompensation. 

Eclampsia. — Blood-pressure  is  usually  high,  but  may 
occasionally,  in  very  severe  cases,  be  low.  Pressures 
have  been  recorded  as  being  over  320  mm.  See  also 
page  92. 


l(i  Cerebral  Hemorrhage. 

Cerebral  Hemorrhage. — The  occurrence  of  a  cerebral 
hemorrhage  is  usually  preceded  by  a  long  period  of 
high  blood-pressure,  accompanying  a  nephritis,  {an 
arteriosclerosis,  or  both.  It  is  not  the  degree  of  per- 
manent elevation  so  much  as  a  sudden  rise  in  an 
already  high  blood-pressure  that  causes  the  vessel  to 
rupture. 

Thus  cases  of  arteriosclerosis,  showing  an  average 
systolic  blood-pressure  of  225  mm.,  have,  following  a 
rise  of  30  or  40  mm.  more,  suffered  an  apoplexy.  On 
the  other  hand,  the  author  has  seen  more  than  one 
case  of  chronic  nephritis  registering  pressures  fre- 
quently above  250  mm.,  occasionally  over  300 — one 
case  almost  310 — without  the  occurrence  of  anything 
more  serious  than  a  mild  cerebral  edema  of  very 
transitory  character.  The  highest  blood-pressure 
readings  occur  in  apoplexy  cerebral  thrombosis, 
depressed  fracture,  intracranial  hemorrhage  and  in 
rapid  growing  cerebral  tumors.  Pressure  up  to  400 
mm.  has  been  recorded  in  these  cases,  while  the 
diastolic  pressure  is  extremely  low  and  the  pulse  rate 
slow.  The  value  of  this  high  pressure  in  these  condi- 
tions is  probably  directed  toward  maintaining  a  fair 
blood  supply  against  the  greatly  increased  intracranial 
tension.  This  emphasizes  the  importance  of  recent 
teaching  that  one  should  not  bleed  or  make  other  effort 
to  lower  the  pressure  in  these  cases,  but  to  operate 
immediately  or  else  administer  atropine  in  large  doses 
to  keep  the  pressure  up,  and  await  developments. 

Migrain. — Migrain  is  usually  accompanied  by  hyper- 
tension, which  may,  according  to  Russell,  be  localized 
and  confined  to  the  arteries  upon  one  side  of  the  body, 
particularly   those   of    the   head.      The   discovery   of 


Blood-Pressure  in  Diseases  of  Eye.  11 

hypertension  in  any  case,  tlie  suljjcct  of  periodic 
attacks  of  hemicrania,  will  furnish  reasonable  f^round 
for  therapeutic  endeavors,  as  it  has  been  shown  that 
the  reduction  of  hypertension  by  eliminative  measures 
in  these  cases  is  often  successful  in  preventinf]^,  or  at 
least  reducino^,  the  severity  of  the  attacks. 

Chronic  Lead  Poisoning. — Chronic  lead  poisoninj^, 
accompanied  by  attacks  of  coHc,  is  usually  attended 
with  an  increase  in  blood-pressure.  Temporary  ele- 
vations of  30  or  40  mm.  have  been  recorded.  The 
fact  may  be  of  value  in  differentiating  colic  due  to 
lead  from  renal  and  biliary  colic  in  which  the  blood- 
pressure  is  low. 

Eye  Diseases. — It  has  long  been  recognized  that  high 
blood-pressure  is  an  important  factor  in  several  eye 
conditions,  but  not  until  recently  has  this  knowledge 
been  put  to  practical  clinical  use  by  the  ophthalmic 
surgeon. 

Arteriosclerotic  changes  in  the  retinal  vessels  will 
immediately  suggest  the  necessity  of  a  blood-pressure 
test.  The  finding  with  the  sphygmomanometer  will 
reveal  the  significance  of  the  eye  condition  by  demon- 
strating the  degree  of  general  arteriosclerosis  present. 
This  knowledge  may  be  put  to  practical  use  by  insti- 
tuting measures  directed  toward  relieving  the  high 
pressure  and  by  modifying  the  individual's  life  and 
habits  in  an  effort  to  arrest  the  arteriosclerotic  process. 

Ocular  Hemorrhage. — Fox  and  Batroft"  report  in 
detail  a  study  of  one  hundred  consecutive  cases  of 
ocular  hemorrhage  in  which  the  blood-pressure  test 
was  employed.  In  80  per  cent,  of  these  cases  hyper- 
tension was  encountered.  40  per  cent  of  the  cases  of 
retinal  hemorrhage  were  accompanied  by  chronic  inter- 


78  Effect  of  Syphilis  on  Blood- Pressure. 

stitial  nephritis.  Arteriosclerosis  was  present  also  in 
27  per  cent,  and  parenchymatous  nephritis  in  13  per 
cent. 

Asphyxia. — The  effect  on  the  cerebral  centers  in  this 
condition,  no  matter  what  its  cause,  is  usually  a 
marked  rise  in  blood-pressure.  This  is  seen  in 
nitrous-oxide  anesthesia.  The  condition  is  also  met  in 
asphyxia  and  cyanosis  from  other  causes,  such  as 
obstruction  to  the  larynx,  diseases  of  lungs,  etc. 

Sjrphilis  of  the  Heart  and  Blood-Vessels. — The  usual 
diagnosis  of  syphilis  of  the  heart  and  blood-vessels 
must  be  based  on  the  same  grounds  which  serve  us 
in  diagnosing  other  syphilitic  manifestations. 

As  the  syphilitic  heart  and  blood-vessels  show 
clinically  nothing  absolutely  characteristic,  nothing 
which  is  not  found  in  other  diseases,  we  should  be 
suspicious  of  syphilis  in  any  patient  with  arterial 
involvement  before  judging  it  to  be  senile  arterio- 
sclerosis, especially  when  the  process  includes  the 
aortic  valves  and  when  incompency  develops  grad- 
ually rather  than  suddenly,  and  when  it  is  not  accom- 
panied by  fever  or  other  signs  of  acute  endarteritis. 

The  Wasserman  and  Leutin  tests  will  show  syphilis 
to  be  present  much  more  often  in  such  diseases  than 
is  usually  believed.  The  relative  rise  in  pressure  will, 
of  course,  depend  largely  upon  the  extent  of  the 
involvement  or  whether  or  not  the  arterial  tree  is 
included  in  the  process. 


Ri.ood-Prkssukk  in   Am  II  ma. 


Diseases  in  Which  the  Blood-I'kessure  is  not 
Greatly  Affected,  But  in  Which  Information 
Obtained  by  the  Sphygmomanometer  is  of 
Value. 

In  asthma  the  value  of  the  blood-pressure  reading 
will  depend  upon  the  variety  of  this  disease  encount- 
ered. 

In  cardiac  asthma  the  pressure  is,  as  a  rule,  low. 
The  finding  of  low  blood-pressure  accompanying  a 
case  of  cardiac  asthma  is  an  indication  for  support  of 
the  heart  and  circulation ;  improved  heart  tone  and  a 
better  circulatory  equilibrium  being  followed  by  a  less- 
ening in  frequency  and  lengthening  of  the  interval 
between  attacks. 

In  asthmatic  attacks  of  other  origin  the  blood-pres- 
sure is  variable,  and  unless  markedly  altered  from  the 
normal,  is  of  little  significance. 

Chronic  Bronchitis. — The  general  condition  of  the 
patient  will  influence  the  blood-pressure  finding.  The 
occurrence  of  hypotension  in  chronic  bronchitis  will 
suggest  the  advisability  of  tonic  measures  directed 
toward  improving  cardiac  and  blood-vessel   tone. 

Neuralgia. — This  condition  is  usually  accompanied 
by  a  reduction  in  pressure,  although  this  may  not  be 
sufficient  in  degree  to  be  noticeable.  This  lowering  of 
blood-pressure  is  in  all  probability  due  to  the  influence 
of  pain  upon  the  vasomotor  system. 

Neurasthenia  is  believed  to  be  accompanied  by  a 
hypotension.  This  appears  to  be  apart  of  the  general 
loss  of  tone  present  in  this  disease  and  may  be  a 
rough  indication  of  the  severity  of  the  exhaustion 
state. 


80  Blooo-Pressure  in  Insanity. 

It  is  well  known  that,  in  active  men  who  are 
approaching  middle  life,  the  insidious  development  of 
arteriosclerosis  or  chronic  nephritis,  or  both,  fre- 
quently shows  itself  in  a  symptom-complex  compris- 
ing irritability,  lack  of  concentration,  a  feeling  of  lost 
confidence  in  one's  self,  sleeplessness,  general  fatigue, 
etc.,  a  combination  of  symptoms  often  occurring  in 
true  neurasthenia.  In  these  cases  a  study  of  blood- 
pressure  is  most  important  as  a  guide  to  diagnosis,  a 
heightened  blood-pressure  often  being  the  one  sign  by 
which  the  true  diagnosis  is  reached. 

Obesity. — Obesity  per  se  has  no  modifying  influence 
on  blood-pressure.  The  relative  level  of  blood-pres- 
sure found  in  any  case  of  obesity  does  not  depend  on 
the  size  of  the  arm  to  which  the  cuff  is  applied,  and 
will  be  normal  for  the  age  of  the  individual  examined, 
unless  the  excessive  fatness  is  in  the  relation  of  cause 
or  effect  with  some  anatomic  or  pathologic  change,  in 
the  heart,  blood-vessels  or  kidneys. 

The  disturbing  effect  of  edema  in  cases  of  obesity 
should  be  remembered,  as  the  presence  of  edema  in 
the  arm  to  which  the  cuff  is  applied  when  taking 
blood-pressure  will  so  interfere  with  the  transmission 
of  pressure  as  to  render  the  observation  valueless. 

In  insanity  (mania),  the  mental  state  of  the  case  at 
the  time  of  examination  will  largely  determine  the 
pressure  level,  which,  if  not  normal,  may  be  either 
slightly  above  or  below  it.  The  characteristic  effect 
of  blood-pressure  altering  complications  will  be  shown 
here  as  in  normal  individuals,  and  here,  as  in  any 
case,  blood-pressure  records  are  valuable,  in  that  they 
may  early  detect  the  onset  of  complicating  affections 
and  may  aid  the  defendant  in  his  efforts  to  prevent 
their  development. 


Blood-Pressure  in  Exophthalmic  Goiter.  81 

Rheumatism  has  been  singled  out  from  the  many 
acute  infections  as  a  condition  for  special  l)lood-pres- 
sure  study.  The  result  of  these  studies  simply  shows 
that  rheumatism,  like  any  other  acute  infection,  is 
accompanied  by  an  elevation  in  pressure  ( 10  to  20 
mm.)  during  the  period  of  invasion,  that  in  severe 
cases  it  may  fall  to  a  marked  hypotension  and  that 
convalescence  is  marked  by  a  gradual  return  to  nor- 
mal unless  influenced  by  the  development  of  compli- 
cations. 

Exopthalmic  Goiter. — The  involvement  of  the  cardiac 
and  vasomotor  centres  in  this  disease  has  been 
shown  to  be  accompanied  by  an  irregular  effect  upon 
the  blood-pressure,  the  stage  of  the  disease  and  the 
severity  of  the  symptoms  determining  the  result.  Thus 
some  observers  have  reported  an  upward  tendency 
and  some  a  downward.  The  study  of  blood-pressure 
may  be  of  value  in  this  disease,  by  showing  the  rela- 
tion of  a  tachycardia  to  a  hypotension,  thus  directing 
the  treatment  upon  more  rational  lines. 

The  cessation  of  menstruation  at  the  climacteric, 
while  physiologic  in  nature,  is  more  often  than  not 
pathologic  in  character,  particularly  that  part  of  the 
phenomenon  involving  the  nervous  system.  In  this 
state,  as  in  all  profound  nervous  disturbances  where 
the  cardiac  and  vasomotor  activities  are  involved,  we 
have  more  or  less  frequent  disturbances  of  vasomotor 
character,  as  shown  by  palpitation,  tachycardia  and 
flushings.  These  are  often  accompanied  by  altera- 
tions in  blood-pressure,  whose  chief  characteristic  is 
a  sudden  variation  in  the  pressure  curve  from  normal 
to  hypo-  or  hypertension  and  back  again. 


82  Blood-Pressure  in  Infectious  Diseases. 

Infectious  Diseases. — In  diphtheria,  scarlet  fever  and 
infectious  diseases  in  general  the  blood-pressure 
shows  some  variation,  which  is  mainly  dependent 
upon  the  period  of  the  disease.  Thus  it  is  found  that 
pressure  has  a  tendency  to  rise  slightly  (5  to  15  mm.) 
during  the  period  of  invasion,  and  then  to  fall  gradu- 
ally during  the  further  progress  of  the  disease  to  a 
hypotension,  to  rise  again  toward  normal  as  conva- 
lescence is  established.  The  occurrence  of  compli- 
cations will  be  shown  by  a  change  in  blood-pressure 
which  fails  to  conform  to  this  rule.  Thus  a  compli- 
cating nephritis  will  be  shown  by  an  early  and  sharp 
rise  in  blood-pressure.  This  may  measure  more  than 
50  mm.  in  twenty-four  hours. 

Typhoid  Fever. — A  slight  primary  rise  may  be  noted, 
but  this  is  a  disease  of  low  blood-pressure,  in  which 
the  readings  are  not  infrequently  all  below  100  mm. 
A  markedly  depressed  blood-pressure  during  the  attack 
is  a  valuable  indication  for  the  need  of  stimulating 
treatment.  A  fall  in  pressure  occurring  suddenly, 
especially  after  the  second  week,  is  usually  indicative 
of  hemorrhage.  A  short,  sharp  rise  is  often  a  valu- 
able sign,  pointing  to  perforation  or  peritonitis  from 
a  deep  ulcer. 

Pneumonia. — Gundrum  and  Johnson  (California 
State  Journal  of  Medicine,  Vol.  10)  report  studies  of 
a  series  of  thirty  cases  of  pneumonia  in  which  the 
blood  pressure  and  pulse  rate  were  taken  simulta- 
neously. Twenty-six  were  lobar  pneumonia.  The 
patients  were  all  adult  males,  20  were  alcoholics.  The 
mortality  was  30%. 

The  blood-pressures  on  admission  show  a  great 
variation,    ranging   from   65   to    122   mm.,   while   the 


KlTK^T   OK    Sa/.VARSA.V.  8i 

pulse  ranged  from  68  to  148.  According  to  Gibson's 
rule  on  admission,  18  patients  were  in  good  condition 
and  12  in  poor.  Of  the  18,  17  recovered  (94%)  and 
one  died  (6%).  Of  the  12  patients  in  poor  condition, 
3  recovered  (257o)  and  9  died  (75%). 

This  study  emphasized  most  powerfully  the  accu- 
racy of  the  observations  made  by  Gibson  several 
years  ago,  and  make  it  imperative  that  every  phy- 
sician should  routinely  employ  the  blood-pressure  test 
in  all  cases  of  pneumonia,  not  only  to  effect  a  better 
prognosis,  but  to  guard  against  the  development  of 
danger  symptoms. 

Injections  of  Salvarsan  and  Neo-Salvarsan. — During 
the  intravenous  injections  of  these  substances  col- 
lapse not  infrequently  occurs  without  a  moment's 
warning.  It  has  been  suggested  by  some  observers 
that  frequent,  rapid  blood-pressure  tests  made  dur- 
ing this  procedure  would  be  a  valuable  guide  as  to 
the  safe  progress  of  the  operation,  and  also  that  this 
test  may  be  used  as  a  guide  to  the  amount  and  rapid- 
ity with  which  the  drugs  may  be  administered. 

Epilepsy. — Owing  to  the  increased  muscular  activ- 
ity occurring  during  an  attack  of  apoplexy,  the  blood- 
pressure  shows  a  rapid  rise  during  the  violent  stage, 
and  a  rapid  fall  usually  to  the  point  of  original  level, 
as  the  paroxysm  subsides  and  coma  develops.  In  a 
patient  seen  during  coma,  where  the  patient's  his- 
tory cannot  be  obtained,  this  fact  may  be  of  aid  in 
differentiating  the  coma  of  epilepsy  from  that  caused 
by  uremia  or  apoplexy,  in  which  high  pressure  is  the 
rule. 


84  Low  Pressure  Cases. 

Pathologic   Conditions   in   Which   the  Blood- 
Pressure  IS  Usually  Below  Normal. 

In  discussing  low  blood-pressure  we  must  classify 
several  varieties  of  this  condition  in  order  to  appre- 
ciate the  underlying  factors  leading  up  to  and  result- 
ing from  this  condition.     They  are  as  follows : — 

Terminal  hypotension  means  the  gradual  lowering 
of  blood-pressure  which  occurs  during  the  last  hours 
or  days  of  life,  and  is  the  direct  result  of  a  gradually 
failing    cardiovascular    mechanism. 

Essential  hypotension  is  met  in  cases  in  which  the 
cause  of  the  low  pressure  cannot  be  explained.  Found 
occasionally  in  members  of  tuberculous  families,  in 
whom  no  definite  signs  of  the  disease  are  shown.  It 
is  a  particularly  common  condition  in  those  cases 
which  are  now  occasionally  recognized  as  having  con- 
genitally  small  hearts  and  narrow  arteries. 

Primary  or  True  Hypotension  is  defined  by  Bishop 
as  being  present  in  those  cases  where  the  blood-pres- 
sure mechanism  has  failed,  but  where  there  has  been 
no  previous  over-demand  for  pressure. 

The  term  Relative  Hypotension  is  applied  to  the 
condition  of  blood-pressure  occurring  in  individuals 
who  have  had  a  distinctively  permanent  elevation  in 
blood-pressure,  but  in  whom  the  pressure  at  the  time 
of  examination  is  found  to  be  normal  or  slightly 
above.  These  cases  are  most  significant,  as  it  is  in 
them  that  we  meet  most  serious  and  distressing  symp- 
toms pointing  to  circulatory  failure,  yet  in  whom  the 
pressure  is  still  above  the  estimated  normal  level. 
This  relative  hypotension  is  sometimes  hard  to  estab- 
lish,  but   if   once   determined   and   satisfactorily   ex- 


Dilatation  of  Hi:ai<t.  85 

plained  the  knowledge  furnishes  a  basis  for  rational 
treatment. 

Diabetes. — The  blood-pressure  in  diabetes  is  low, 
often  being  found  below  100  mm.  The  chief  value 
of  the  blood-pressure  test  in  this  disease  is  in  the 
detection  of  complications  involving  the  kidneys.  A 
rising  blood-pressure  found  in  the  course  of  a  case 
of  diabetes  will  direct  the  attendant's  attention  to 
the  kidneys,  when  a  urinalysis  will  often  explain  the 
origin  of  the  "turn  for  the  worse." 

Cardiac  Dilatation. — As  would  be  expected,  dilata- 
tion of  the  heart  is  accompanied  by  a  dangerously  low 
blood-pressure,  which  may  be  sufficiently  low  to 
endanger  life.  The  finding  of  a  low  pressure  in  a 
cardiac  case  will  plainly  indicate  treatment  directed 
toward  preventing  syncope. 

Improvement  in  the  condition  of  caridac  contrac- 
tion will  be  shown  by  a  gradually  rising  pressure, 
accompanied  by  a  falling  pulse  rate  and  an  increase 
in  the  pulse  pressure. 

Shock  and  Collapse. — These  are  two  complications 
which  may  develop  under  a  variety  of  circumstances 
in  many  disease  conditions.  In  many  cases  which  are 
in  an  apparently  good  condition,  the  sudden  develop- 
ment of  one  of  these  complications  may  result  fatally. 
It  becomes,  therefore,  of  great  importance  to  antici- 
pate the  onset  of  these  complications  and,  upon  noting 
the  warning  signs,  to  institute  measures  for  their 
relief.  This  form  of  procedure  is  in  many  cases  very 
successful.  During  surgical  operations  under  anaes- 
thesia the  sphygmomanometer  is  of  great  service  in 
detecting  early  circulatory  failure  from  either  heart 
failure  or  vasomotor  paralysis.    Many  surgeons,  among 


86  Blood -Pressure  After  Hemorrhage. 

them  Bloodgood,  of  Baltimore,  now  employ  the  blood- 
pressure  test  in  all  operations,  depending  upon  it  for 
the  continued  safety  of  their  patients.  (See  chapter 
on  Surgery,  page  95.) 

Hemorrhage. — Closely  allied  to  the  preceding,  at 
least  in  the  seriousness  and  suddenness  of  its  develop- 
ment, is  hemorrhage,  either  external  or  internal.  Fol- 
lowing external  hemorrhage,  the  blood-pressure  will 
be  found  below  normal,  and  the  amount  of  this  lower- 
ing will,  in  a  rough  way,  indicate  the  amount  of  blood 
lost.  This  fact  is  true  only  when  the  observations 
immediately  succeed  the  bleeding.  The  circulation 
very  rapidly  regains  its  normal  equilibrium,  so  that 
after  hemorrhage  of  300  to  400  c.c,  causing  a  reduc- 
tion of  30  to  40  mm.,  it  is  soon  overcome  and  the 
effect  as  demonstrated  by  the  sphygmomanom)eter 
lost.  ■  "^ 

In  those  diseases  in  which  internal  hemorrhage  is  a 
complication,  and  after  surgical  operations  where 
there  is  danger  of  secondary  hemorrhage,  the  fre- 
quent employment  of  the  sphygmomanometer  is  of 
greatest  value  in  detecting  this  complication  long 
before  the  patient  is  exsanguinated  or  in  a  dangerous 
condition. 

To  be  of  greatest  value  in  detecting  hemorrhage, 
the  blood-pressure  test  should  be  made  as  often  as  the 
pulse  and  temperature  is  taken,  and  should  be  recorded 
on  the  combined  chart  which  is  made  for  this  purpose 
(see  page  32).  Used  in  this  manner,  a  rising  pulse 
rate  and  a  falling  blood-pressure,  even  when  the 
change  is  slight,  will  direct  examination  along  such 
lines  as  will  prove  or  disprove  the  suspicion. 


Blood-Pressure  in  Tuberculosis.  A7 

Cerebral  Embolism. — From  the  differential  diagnostic 
standpoint,  in  cases  where  the  decision  rests  between 
cerebral  hemorrhage  and  embolism,  the  blood-pressure 
test  is  of  greatest  value,  as  it  is  well  recognized  that 
the  pressure  in  apoplexy  is  always  high,  often  above 
300,  while  in  embolism  the  reverse  is  usually  the  case. 
When  a  previous  history  is  unobtainable,  this  test 
may  be  the  one  deciding  factor. 

Jaundice. — Blood-pressure  is  usually  low  in  cases  of 
simple  catarrhal  jaundice.  This  is  probably  due  to 
the  effect  of  absorption  of  intestinal  products  of 
decomposition  arising  from  interference  in  digestion. 
It  may  be  said  that  in  practically  all  mild  toxemias, 
particularly  of  gastro-intestinal  origin,  the  tendency 
of  blood-pressure  is  downward,  often  remaining  for 
some  time  between  100  and  110. 

Pulmonary  Tuberculosis  is  a  disease  of  low  pressure. 
The  degree  of  lowering  of  pressure  is  a  good  index  of 
the  severity  of  the  infection  and  the  progress  of  the 
case  toward  recovery  or  otherwise.  Good  authority 
teaches  that  blood-pressure  gradually  and  steadily 
falls  in  cases  of  progressive  pulmonary  tuberculosis  ; 
that  it  becomes  stationary  and  tends  to  rise  as  the 
disease  becomes  arrested,  and  that  a  rising  pressure 
means  a  good  prognosis,  as  the  blood-pressure  practi- 
cally never  returns  to  normal  in  unarrested  cases. 

The  effect  of  high  altitude  on  cases  of  pulmonary 
tuberculosis  is  to  cause  a  rise  in  pressure;  this  rise 
being  beneficial  in  that  its  effect  is  to  increase  the  force 
and  volume  of  the  circulation. 

Peters  and  Bullock  (Medical  Record,  September 
14th,  1912)  sum  up  our  knowledge  of  blood  pressure 
in  this  disease,  as  follows : 


88  Blood-Pressure  in  Anemia. 


1.  Blood  pressure  is  increased  at  elevations  of  6^000 

feet. 

2.  The  pressure  of  consumptives  is  higher  here  than 

at  sea  level. 

3.  The  pressure  tends  to  increase  with  continued 
residence. 

4.  From  a  prognostic  standpoint  the  blood  pressure 
findings  are  of  great  value  in  tuberculosis. 

5.  There  is  no  relation  between  the  degree  of  involve- 
ment and  blood  pressure,  but  there  is  a  constant  rela- 
tion between  toxemia  and  blood  pressure. 

6.  The  pressure  is  increased  with  pulmonary  hem- 
orrhage. 

Anemia,  Chlorosis  and  Exhaustion  States. — An  impov- 
erished blood  and  a  reduced  physical  tone,  affecting  all 
organs  and  tissues  of  the  body,  results  in  loss  of  vaso- 
motor and  cardiac  tone,  which  is  easily  demonstrated 
by  the  sphygmomanometer  in  varying  degrees  of 
hypotension.  The  chief  value  of  these  studies  is  in 
directing  the  physician's  attention  to  the  need  of  abso- 
lute recumbency  and  rest,  in  order  to  avoid  syncope 
from  a  too  greatly  lowered  blood-pressure. 

Cholera. — The  great  loss  of  fluid  in  cholera  results 
in  such  a  depression  in  blood-pressure  that  measures 
to  combat  collapse  are  urgently  demanded.  It  has  been 
demonstrated  that  large  amounts  of  saline  introduced 
either  subintravenously  or  intravenously  accomplish 
this  rest  most  satisfactorily.  During  the  transfusion 
the  sphygmomanometer  is  the  best  guide  to  the  effect 
of  the  procedure. 

If  diarrhea  is  profuse,  it  will  result  in  a  lowering  of 
blood-pressure.  Under  ordinary  conditions  this  fall 
will  be  insufficient  to  demand  special  treatment,  but  in 


Blood-Pressure  in  Delirium, 


89 


greatly  debilitated  persons,  as  typhoid  cases  after 
hemorrhage,  the  sphygmomanometer  may  be  of  great 
service  in  demonstrating  a  dangerously  low  pressure. 
In  Alcoholic  delirium^  vasomotor  paralysis  present, 
this  usually  causes  a  marked  lowering  of  the  systolic 
pressure,  therefore  employment  of  sedative  measures 
or  hot  pack,  which  might  further  cause  a  lowering  of 
pressure  must  be  used  with  caution  for  fear  of  sub- 
sequent collapse. 


Position  for  Observation,  Patient  in  Bed. 


CHAPTER  VI. 
PREGNANCY,  TOXEMIA  AND  ECLAMPSIA, 


Importance  of  Blood-Pressure  Test  in     . 

91 

Normal  Pressures  in           - . 

91 

Early  Signs  of  Toxemia     . 

91 

Effects  of  Toxemia     . 

92 

Dangerous   Pressures 

93 

CHAPTER  VI. 
PREGNANCY,  TOXEMIA  AND  ECLAMPSIA 

The  obstetrician  of  the  present  day  must  have  con- 
stant recourse  to  the  blood-pressure  test  if  he  would 
maintain  the  lead  in  his  profession.  The  sphygmoma- 
nometer now  ranks  with  urinalysis  in  the  examination 
of  pregnant  women.  In  the  blood-pressure  test  we 
have  a  most  valuable  means  of  detecting  early  toxemias, 
which  often  lead  to  the  eclamptic  state.  The  blood- 
pressure  test  is  capable  of  early  furnishing  very 
definite  indications  of  departures  from  normal  me- 
tabolism in  the  pregnant  women. 

Early  Sign  of  Toxemia. — John  Cooke  Hirst  (A^.  Y. 
M.  J.,  June  11,  1910)  states  that  the  earliest  and  most 
constant  sign  of  toxemia  in  the  latter  half  of  preg- 
nancy is  a  high  and  constantly  rising  blood-pressure, 
and  this  symptom  may  precede  albuminuria  and  all 
other  constitutional  signs  of  an  impending  eclamptic 
attack. 

Examinations  of  normal  non-pregnant  women, 
showing  no  signs  of  heart  or  kidney  lesions,  gave  an 
average  systolic  pressure  with  the  Faught  instrument 
of  112  mm.  He  then  took  the  pressure  of  100  normal 
pregnant  women,  these  showing  no  signs  of  albumin 
or  any  sign  of  toxemia,  and  found  the  pressure  to 
average  118.     He  found  that  these  figures  held  good 

91 


92  Toxemia  on    Blood-Pressure. 

up  to  approximately  seven  and  a  half  months,  after 
which  date  there  was  a  gradual  rise,  so  that  in  the 
middle  of  tlie  last  month  of  pregnancy  a  fairer  average 
was  124  mm.;  with  subsidence  of  the  uterus  the 
pressure  showed  a  slight  fall.  This  coincides  with  the 
observations  of  H.  C.  Bailey  (S.  G.  and  O.,  vol.  xiii, 
No.  5,  page  485),  who  made  1,136  systolic  readings  on 
145  normally  pregnant  women  in  Bellevue  Hospital. 
The  average  normal  systolic  pressure  was  118  mm. 
He  states  that  his  readings  varied  greatly,  but  that  the 
high  limit  was  rarely  passed.  Twenty-eight  per  cent, 
showed  a  variation  of  from  25  to  30  mm.  in  the  course 
of  several  days.  The  study  of  the  nitrogen  partition 
of  the  urine  of  these  women  showed  no  marked 
changes,  so  that  this  was  of  very  little  value.  In  con- 
clusion, he  says  that  changes  of  less  than  30  mm.  above 
the  normal  average  118  means  very  little  from  a  prac- 
tical standpoint,  and  that  at  the  onset  of  labor  the 
pressure  usually  rises  during  the  first  and  second 
stages  of  140  and  150  mm.  taken  between  the  pains. 
Again  another  most  careful  observer,  Hubert  J. 
Starling  {Lancet,  Sept.  10,  1910),  reports  a  study  of 
blood-pressure,  covering  a  period  of  five  years  in 
pregnant  women  in  whom  the  normal  average  was 
from  110  to  120  mm. 

All  these  observers  are  most  emphatic  in  their  state- 
ment that  routine  blood-pressure  observations  should 
be  made  a  part  of  the  periodical  examination  of  preg- 
nant women  and  that  with  the  development  of  sus- 
picious signs  and  advance  toward  the  end  of  the  gesta- 
tion, the  intervals  between  the  tests  should  be  short- 
ened, and  that  the  test  should  not  be  omitted  during  the 
puerperium,  as  in  this  state  women  may  develop 
serious  toxemia  and  eclamptic  attacks. 


DangilRousi-y   High    Pressures.  93 

Dangerous  Pressures. — Thus  from  the  analysis  of 
blood-pressure  readings  made  by  many  observers  we 
believe  that  a  pressure  of  150  must  be  taken  as  a 
danger  limit,  and  that  any  pressure  above  this  demands 
vigorous  investigation  and  treatment. 

T.  M.  Green  {Boston  M.  and  S.  J.,  April  28,  1910) 
conveniently  divides  toxemia  of  pregnancy  in  three 
divisions  : 

First,  moderate  increase  in  blood-pressure. 

Second,  marked  increase  in  blood-pressure. 

Third,  extreme  increase  in  blood-pressure. 

To  these  may  be  added  the  fourth  which  is  suggested 
by  Hirst  and  by  Bailey,  namely,  fourth,  extreme 
eclamptic  condition  in  which  the  blood-pressure  may 
be  low. 

In  the  first  two,  symptoms  disappear  and  blood- 
pressure  falls  after  delivery.  In  the  third  and  fourth, 
blood-pressure  continues  abnormal  and  the  disease 
usually  progresses  to  a  rapidly  fatal  termination. 

The  blood-pressure  seems  to  bear  definite  relation 
to  the  type  of  case,  and  its  frequent  observation  should 
be  of  great  value  both  in  prognosis  and  in  treatment. 

According  to  Hirst,  the  highest  pressure  rei)orted 
by  him  in  the  toxemic  case  without  eclampsia  was  192 
mm.  The  highest  in  eclampsia  was  320  mm.  How 
high  he  was  unable  to  detern]ine,  because  the  mercury 
ran  out  of  the  top  of  the  tube  before  the  pulse  was 
shut  off. 


CHAPTER  VII. 
BLOOD-PRESSURE  IN  SURGERY  AND 


ANESTHESIA, 

Importance  of  Routine  Study         ....         95 

Operations  After  Accidents 

96 

Wlien  to  Operate 

97 

Pulse  and  Pressure  Before  Anesthesia 

99 

Nitrous  Oxide 

100 

Nitrous  Oxide  with  Oxygen 

101 

Dental  Anesthetics 

101 

Effect  of  Anesthesia 

104 

Method  of  Testing      . 

106 

Ether 

108 

Chloroform 

108 

Ethyl  Chloride     . 

108 

Spinal  Anesthesia 

109 

Local  Anesthesia 

109 

CHAPTER  VII. 

BLOOD-PRESSURE  IN  SURGERY  AND  ANESTHESIA 
DENTAL  ANALGESIA 

Importance  of  Routine  Study. — Joseph  C.  Bloodgood 
{International  Journal  of  Surgery,  January,  1913) 
states  that  in  St.  Agnes'  Hospital  during  the  last  two 
years  blood-pressure  records  have  been  made  a 
routine  in  connection  with  investigations  of  nitrous- 
oxide  and  oxygen  anesthesia.  From  these  observa- 
tions he  concludes  that  "I  am  confident  from  this 
experience  that  the  blood-pressure  apparatus  is  an 
instrument  of  precision  which  will  be  more  helpful 
than  anything  yet  devised  to  help  the  surgeon  to 
accurately  judge  the  condition  of  his  patient  and  to 
act  accordingly.  The  blood-pressure  records  serve 
to  warn  the  surgeon  of  shock  long  before  the  pulse, 
respiration  or  any  other  clinical  sign." 

'Tn  all  of  my  cases  the  blood-pressure  reading  is 
taken  in  the  ward  the  day  before  the  operation,  on 
the  morning  of  the  operation,  when  the  patient 
reaches  the  operating  room,  before  the  anesthesia 
is  administered  and  repeatedly  during  the  operation. 
It  is  most  important  to  note  the  blood-pressure  after 
the  anesthesia  is  off  and  before  the  patient  is  trans- 
ported to  the  ward.  When  the  blood-pressure  is  low 
(110   or   less)    the  patient  is   not   removed   from  the 

95 


96  Operations   After  Accidents. 

table,  but  is  kept  in  an  adjoining  roonn  until  the  reac- 
tion is  satisfactory.  Collapse  after  their  removal  to 
their  beds  will  thus  be  prevented." 

This  investigator  has  also  observed  that  when, 
after  painful  manipulation,  instead  of  a  primary  rise 
there  is  a  fall  in  pressure,  and  when  the  blood-pres- 
sure does  not  rise  again  after  the  painful  manipula- 
tion is  discontinued,  these  must  be  looked  upon  as 
warnings  of  impending  shock. 

As  an  indication  for  venesection,  saline  infusion  or 
the  Murphy  treatment,  and  as  a  guide  to  the  beneficial 
efifect  of  these  several  measures,  the  sphygmoma- 
nometer is  pre-eminent. 

Operations  after  Accidents. — The  question  of  the  safe 
outcome  of  any  proposed  operation  frequently  deter- 
mines the  question  for  or  against  operating  on  patients 
who  have  suffered  accidents.  This  question  really 
amounts  to  a  determination  of  the  degree  of  shock 
which  the  case  has  already  suffered  and  an  estimation 
of  how  much  more  shock  the  case  is  able  to  bear. 
This   is   best   determined  by   the   sphygmomanometer. 

Bearing  on  this  phase  of  the  subject,  Colcord  (Inter- 
national Journal  of  Surgery,  June,  1913)  has  contrib- 
uted some  valuable  data  on  the  effect  of  traumatism 
on  blood-pressure.  He  noted  that  when  there  is  injury 
to  the  spinal  cord  or  epididymis,  there  is  an  immediate 
fall  in  blood-pressure.  That  severe  injury  to  the 
thigh  or  hip-joint  often  has  the  same  effect.  Frac- 
tures of  the  base  when  accompanied  by  severe  trauma, 
result  in  powerful  inhibition  of  the  heart  and  respira- 
tion, sometimes  resulting  in  sudden  death.  The  same 
inhibitory  effect  is  noted  in  most  any  region  supplied 
by  the  superior  laryngeal   nerve,   and   that   operation 


When  to  Operate.  97 


upon  the  larynx,  pharynx  and  nasal  chambers  often 
show  these  reflexes. 

These  same  considerations  enter  into  tlic  question  of 
operating  in  extreme  conditions,  resulting  from  rapidly 
developing  or  neglected  surgical  conditions. 

The  sphygmomanometer,  in  conjunction  with  the 
pulse,  is  the  quickest  and  surest  means  at  our  com- 
mand with  which  to  arrive  at  the  proper  decision,  and 
the  blood-pressure  test  has  undoubtedly  been  the  means 
of  saving  many  lives  under  the  conditions  mentioned 
above. 

When  to  Operate. — A  fair  or  normal  blood-pressure 
is  always  a  good  indication  of  the  state  of  the  vaso- 
motor system,  because  vasodilatation  invariably  results 
in  hypotension,  and  the  degree  of  hypotension  fairly 
indicates  the  severity  of  shock. 

An  extremely  rapid  pulse,  associated  either  with  a 
lowered  blood-pressure  or  with  one  approximately 
normal,  is  an  indication  of  a  poor  or  shocked  heart- 
muscle — one  unlikely  to  withstand  the  strain  of  anes- 
thesia. 

The  sphygmomanometer  is  often  the  means  of  deter- 
mining the  safe  time  to  operate.  Thus  a  dangerous 
condition  of  the  cardiomotor  and  vasomotor  mechan- 
ism will  indicate  appropriate  restorative  treatment, 
and  will  demonstrate  plainly  whether  such  measures 
are  successful.  The  surgeon  will  thus  be  guided  in 
his  judgment  as  to  the  right  time  to  operate. 

The  newer  methods  of  anesthesia  have  done  much 
to  improve  the  character,  method  and  technic  of  their 
administration.  The  chief  effort  of  the  anesthetist  of 
today  is  to  gain  relaxation  with  a  minimum  amount 


98 


Ether  Vapor  Apparatus. 


of  the  anesthetic,  and  to  maintain  anesthesia  at  any- 
given  level  without  fluctuations.  Proper  administra- 
tion will  produce  a  minimum  of  after  sickness,  prompt 
and  thorough  recovery  from  the  anesthesia,  a  minimum 
of  shock  and  an  economic  use  of  the  anesthetic.  All 
factors  contributing  to  the  future  safety  and  welfare 
of  the  patient. 

PATENTS     PENDING 


Fig.  20— Dr.  Hill's  Warm  Vapor  Ether  Inhaler. 


PATENTS    PENDING 


Fig.   21 — Dr.   Hill's   Warm  Vapor   Ether-Oxygen  Apparatus. 

In  no  other  way  can  the  surgeon  or  anesthetist 
obtain  the  same  satisfactory  demonstration  of 
normal  anesthetization  as  by  the  continuous  use  of 
the  sphygmomanometer. 


Pulse  and  Pressure  Before  Anesthesia.  99 

It  is  not  necessary  to  employ  a  large  or  expen- 
sive apparatus  to  obtain  satisfactory  results  with 
warm  ether  vapor.  The  ether  vaporizer  and  the 
ether  and  oxygen  apparatus  devised  by  R.  Franklin 
Hill,  M.  D.,  of  Philadelphia,  shown  in  the  accom- 
panying cuts,  very  successfully  administers  a  uni- 
form percentage  of  warm  ether  vapor  alone  or  in 
connection  with  oxygen. 

The  ether  vaporizer  is  not  much  larger  than  the 
usual  Allis  cone.  It  has  double  walls,  the  spaces 
between  which  are  filled  with  a  paraf^n  oil,  so  that 
when  placed  in  the  sterilizer  or  hot  water  before 
using,  it  absorbs  sufficient  heat  to  vaporize  and 
warm  the  ether  passing  through  it. 

The  advantages  of  this  apparatus  are  shortened 
time  to  produce  anesthesia,  almost  complete  elimi- 
nation ol  the  stage  of  excitement,  breathing  is  more 
quiet  and  a  smaller  amount  of  ether  is  employed, 
both  during  anesthetization  and  in  maintaining  that 
condition.  The  tendency  to  post-operative  nausea, 
vomiting  and  pneumonia  is  lessened  greatly.  The 
amount  of  ether  is  under  complete  control. 

The  ether  and  oxygen  apparatus  has  recently  met 
with  approval  by  many  surgeons.  It  can  be  em- 
ployed to  give  ether  alone  or  in  connection  with 
oxygen.  Heat  is  obtained  with  a  carbon  electric 
lamp. 

This  apparatus  is  particularly  useful  for  opera- 
tions upon  the  head  or  face  in  which  the  cone  in- 
haler cannot  be  used. 

The  face  piece  is  detachable  for  sterilization. 

Pulse  and  Pressure  before  Anesthesia. — The  blood- 
pressure  and  pulse  rate  immediately  preceding  anes- 
thesia is  usually  found  above  normal.  This  is  due  to  the 


100 


Nitrous-Oxide  Anesthesia. 


excitement  attending  the  approach  of  a  radical  pro- 
cedure, and  should  be  taken  into  consideration  by  the 
surgeon.  This  temporary  disturbance  in  blood-pres- 
sure and  pulse  rate  suggests  the  necessity  of  prelim- 
inary tests  made,  in  quiet  surroundings,  the  day  before 
operation.  This  will  establish  the  normal. 


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Nitrous-Oxide. — During  the  first  moments  of  admin- 
istration of  pure  nitrous-oxide,  the  blood-pressure 
mounts  rapidly  upward,  the  rise  equaling  in  some  cases 
50  or  more  mm.  At  the  same  time  the  pulse  becomes 
very  full  and  strong,  while  the  rate  may  remain  sta- 
tionary or  rise  slightly.  See  Fig.  22-  Immediately 
succeeding  the  anesthesia  period,  the  pressure  rapidly 
falls  and  the  pulse  rate  rises.  This  effect  of  nitrous- 
oxide  on  blood-pressure  will  suggest  caution  in  admin- 
istering it  to  cases  of  arteriosclerosis  or  in  any  case 
where  the  patient's  level  is  much  above  normal. 


DliNTAL    AnESTIIKTICS.  101 

Nitrous-Oxide  Combined  with  Oxygen. — The  combined 
administration  of  nitrous-oxide  and  oxygen  Ijy  one  of 
the  several  apparatus  now  employed  for  this  purpose  is 
unattended  by  any  of  the  alarming  symptoms  or  rise 
in   bloo(l-i)rcssure  noted  under  nitrous-oxide  alone. 

Idiis  combination  properly  administered  is  capable 
of  maintaining  partial  or  profound  anesthesia,  for 
prolonged  periods  without  materially  affecting  blood- 
pressure  or  pulse  rate.  The  rise  in  pressure  which 
accompanies  the  N.O  is  either  greatly  reduced  or 
entirely  prevented  by  a  proper  percentage  of  oxygen. 
The  accompanying  chart  is  taken  from  Dr.  Faught's 
collection  and  well  shows  the  result  of  a  proper  admin- 
istration of  this  combined  anesthesia. 

Notes  on  the  Administration  of  Anesthetics  by 
Dental  Practitioners. 

The  recent  perfection  and  wide  employment  of 
anesthesia  of  all  varieties  by  dental  practitioners 
makes  it  imperative  that  its  administrators  should 
have  not  only  a  working  knowledge  of  the  methods 
of  administration,  but  that  they  should  also  be  famil- 
iar with  at  least  the  more  important  points  of  general 
pathology,  particularly  that  which  applies  to  the  heart, 
the  circulation  and  the  kidneys,  in  order  that  they 
may  be  able  to  detect  departures  from  normal,  which 
might  be  magnified  by  the  administration  of  any  anes- 
thetic, and  so  result  in  serious  damage  to  the  patient, 
if  not  in  actual  loss  of  life.  Anyone  attempting  a 
prolonged  administration  of  any  anesthetic  who  has 
not  this  knowledge  places  both  his  patient's  life  and 
his  own  reputation  in  needless  jeopardy. 


102 


Administration  of  Nitrous  Oxide. 


In  a  recent  discussion  of  this  subject,  Dr.  Charles 
S.  Tuttle,  a  dental  anesthetist,  formulated  two  perti- 
nent questions  which  every  administrator  of  dental 
anesthetics    should   be   compelled   to   answer : 


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YiG.  25— Administration  of   Pure  Nitrous  Oxide. 


"To  whom  is  it  safe  to  administer  an  anesthetic?" 
"What  anesthetic  should  be  selected  to  produce  the 
best  results  with  the  least  disturbance?" 

He  then  cites  the  common  but  dangerous  opinion  of 
many  dental  surgeons  who  have  for  years  employed 
nitrous-oxide :  "If  the  patient  is  able  to  walk  up  the 
stairs  to  my  office  without  prostration,  I  consider  him 
fit" 


Administration    of    Somnoform. 


If).' 


Dr.  Tuttle's  reply  to  the  first  proposition  is  this : 
"The   safety   in   administering  an   anesthetic   either 
by  a  physician  or  a  dentist  depends  upon  his  posses- 
sion   of    the    requisite    knowledge,    his    skill    and    his 
experience."     Here  he  refers  undoubtedly  to  the  pos- 


FiG.  24 — Administration  of   Somnoform. 


session  of  a  knowledge,  first  of  the  physiology  and 
pathology  of  the  circulation  ;  second,  to  adequate  skill, 
not  only  in  the  direct  administration  of  an  anesthetic, 
but  also  to  an  ability  to  follow  the  course  of  the 
administration  and  to  recognize  the  development  of 
danger  signals  ;  and  third,  his  experience,  not  only  in 
the  administration  of  an  anesthetic  by  proper  manipu- 


104  Effect  of  Different  Anesthetics. 

lation  of  the  apparatus,  but  also  adequate  experience 
in  employing  those  means  which  are  recognized  as 
the  proper  aids  to  diagnosis  as  applied  to  the  heart, 
circulation  and  kidneys. 

In  all  their  writings  the  more  advanced  dental 
anesthetists  have  laid  stress  upon  the  importance  of 
the  blood-pressure  test,  and  possession  of  a  working 
knowledge  of  the  blood-pressure  and  its  variations 
under  dental  anesthetics.  We  find  that  it  is  by  means 
of  the  sphygmomanometer,  which  is  the  greatest 
single  aid  in  the  proper  study  of  cases  before,  during 
and  after  the  administration  of  anesthesia,  and  it  has 
been  proven  that  those  who  employ  this  study  not 
only  obtain  better  results  in  the  average  case,  but  are 
also  better  able  to  select  their  anesthetic,  while  the 
danger  of  the  anesthetic  is  largely  removed  together 
with  the  elimination  of  those  complications  which  so 
often    follow    a    poorly    administered    anesthetic. 

From  the  knowledge  of  the  blood-pressure  in  the 
individual  case  requiring  the  anesthetic  we  are  better 
able  to  judge,  not  only  as  a  relative  safety  of  the 
administration,  but  are  also  helped  in  the  selection 
of  the  anesthesia,  for  it  has  been  found  that  different 
anesthetics  react  upon  the  heart  and  circulation  in 
different  ways.  It  is  now  known  that  nitrous  oxide 
alone  produces  a  marked  and  rapid  rise  in  blood- 
pressure  (see  Fig.  23),  and  that  the  administration 
of  oxygen  in  conjunction  with  the  nitrous  oxide  in 
proper  percentage  largely  controls  this  rise  (see  Fig. 
22).  Chloroform,  ethyl  chloride  and  soninoform  all 
have  a  direct  tendency  through  their  action  upon  the 
vasomotor  system  to  cause  a  continued  fall  in  blood- 
pressure   throughout  the  length  of  their  administra- 


Anesthesia  By  Dentist. 


105 


tion,  while  ether  causes  a  prompt  rise  followed  by  a 
fall  to  above  normal,  which  when  properly  adminis- 
tered is  followed  by  but  slight  further  variation,  even 


Fig.     25 — Illustrating     Application     of     Sphygmomanometer 
During  Dental  Anesthesia. 


106  Method  of  Testing  in  Anesthesia. 

during  administrations  .lasting  several  hours  (see 
Fig.  22). 

It  will  be  seen  at  once  that  the  danger  of  adminis- 
tration of  nitrous  oxide  increases  in  proportion  as 
the  patient's  pressure  is  above  normal.  That  ether  is 
probably  the  safest  anesthetic  Avhich  we  have  for  pro- 
longed operations,  that  chloroform,  ethyl  chloride  and 
somnoform  on  account  of  their  effect  on  blood-pres- 
sure may  at  any  time  suddenly  become  dangerous, 
even  in  the  normal  case  where  the  original  pressure 
is  found  to  be  normal  (see  Fig.  26)  and  that  probably, 
in  high  pressure  cases,  these  may  be  safer  than  other 
anesthetics  because  of  their  tendency  to  cause  a  fall 
rather  than  a  rise  during  anesthesia. 

Following  the  lead  of  the  more  advanced  surgeons, 
it  is  recommended  that  dentists  should  regularly 
employ  the  blood-pressure  test,  and  that  an  effort 
should  be  made  to  obtain  the  normal  level  before  the 
administration  of  the  anesthetic,  which  will  serve  as 
a  guide  later.  During  the  anesthesia  period  blood- 
pressure  observations  should  be  made  continually  at 
intervals  of  one,  two  or  three  minutes,  depending  on 
the  nature  and  duration  of  the  case,  and  that  the  blood- 
pressure  should  be  watched  for  several  hours  after 
the  administration  whenever  chloroform,  somnoform 
or  ethyl  chloride  is  used  for  any  length  of  time. 

Method  of  Testing. — It  is  only  necessary  to  consider 
the  systolic  pressure,  an  observation  which  can  be 
taken  by  anyone,  even  an  untrained  assistant,  after 
a  few  lessons.  Intelligent  patients  have  learned  to 
appreciate  the  necessity  of  these  observations  and  are 
very   willing  to   submit  to   them.     It  is   unnecessary 


Application  of  Gibson's  Rule. 


107 


here  to  go  into  any  detail  in  regard  to  the  physiology 
and  pathology  of  the  circulation  or  of  anesthesia  from 
the  surgical  standpoint,  as  these  points  are  all  fully 
explained  in  the  following  pages. 

Finally  the  observations  of  Gibson  and  others  upon 
the  relation  of  blood-pressure  and  pulse  are  significant 
and  have  a  direct  bearing  from  the  dental  standpoint. 
It  has  been  found  in  normal  conditions  that  the  blood- 
pressure  in  mm.  Hg.  remains  ordinarily  above  the 
pulse-rate  in  beats  per  minute,  and  that  change  in  the 
relation  of  these  figures  is  a  sign  or  danger  which 
should  call  for  appropriate  measure  to  re-establish 
the  normal  relation,  whether  this  is  the  withdrawal 
of  the  anesthetic,  an  increase  in  the  amount  of  oxygen 
or  the  employment  of  active  restorative  measure. 


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which    shows    graphically    the 


108  Ether — Chloroform — Ethyl  Chloride. 


Usual     Effect     of     Different     Anesthetics  on 
Blood-Pressure. 

Ether  alone  causes  a  moderate  rise  in  blood-pressure 
during  the  early  period  of  its  administration.  Strug- 
gling causes  a  further  rise,  together  with  an  accelera- 
tion in  pulse  rate.  These  changes  rapidly  subside  as 
the  stage  of  anesthesia  is  reached,  so  that,  under  ordi- 
nary circumstances,  the  pulse  and  blood-pressure 
remain  at  or  about  the  same  levels  on  the  chart  as 
were  noted  prior  to  the  removal  of  the  case  to  the 
operating  room. 

Dangerous  symptoms  occurring  during  the  course 
of  operation  will  usually  early  be  shown  by  changes 
in  pulse  rate  and  blood-pressure;  the  blood-pressure 
falling  and  the  pulse  rate  rising,  so  that  this  change 
developing  during  anesthesia  will  indicate  to  the  sur- 
geon the  advisability  of  haste  in  completing  the  opera- 
tion or  the  necessity  of  dividing  the  operation  into 
two  stages. 

Chloroform  is  a  dangerous  anesthetic  under  all  cir- 
cumstances and  its  use  should  always  be  attended  with 
great  care.  It  has  been  demonstrated  that  blood-pres- 
sure falls  gradually  from  the  very  beginning  of  the 
administration.  This  fall  may  occur  during  the  first 
few  minutes  and  be  so  great  as  to  endanger  life.  When 
this  anesthetic  is  used,  the  blood-pressure  test  should 
be  continuously  employed,  and  every  .effort  made  to 
avoid  a  dangerous  fall  in  blood-pressure. 

Ethyl  Chloride. — This  drug,  according  to  the  last 
report  of  the  anesthesia  commission  of  A.  M.  A.,  is  a 
very  safe  anesthetic,  and  observations  on  blood-pres- 
sure seem  to  bear  this  out.     There  is  a  tendency  to  a 


Spinal   Anesthesia — Local    Anesthesia.  109 

fallinj:^  pressure  \\Iu\li,  liowexcr,  is  not  j^rcat,  ancl 
which  is  easily  controlled  hy  the  admission  of  suffi- 
cient air. 

Spinal  Anesthesia. — According  to  Colcord,  in  surgi- 
cal anesthesia  there  is  a  rise  at  first,  due  in  part  to 
mental  excitement,  puncture,  drawing  off  of  fluid  and 
to  the  injection  of  the  solution.  This  lasts  from  15 
to  20  minutes ;  then  the  pressure  falls  to  near  the 
normal  line  and  the  chart  shows  remarkably  few 
excursions  above  or  below  during  the  operation. 
According  to  Gushing,  if  the  anesthesia  extends  too 
high  into  the  dorsal  cord,  paralysis  of  the  efferent 
nerves  to  the  splanchnic  area  may  be  induced,  causing 
a  dangerous   fall  in  blood-pressure. 

Local  Anesthesia. — In  local  anesthesia  several  fac- 
tors influence  blood-pressure.     These  are  : 

1.  Cocaine  itself  produces  a  rise  in  blood-pressure. 

2.  The  mental  excitement,  always  a  variable  fac- 
tor, may  produce  a  rise. 

3.  Any  pain  from  injury  to  nerves,  not  anes- 
thetized, will  cause  a  rise. 

4.  Injury  to  nerves  completely  anesthetized  will 
cause  no  change  in  blood-pressure. 

Operative  Effect  on  Blood-pressure. — The  surgeon 
should  be  in  possession  of  the  facts  concerning  the 
influence  of  operative  procedures  on  blood-pressure. 
Thus,  when  the  skin  is  incised,  there  is  usually  an 
abrupt  fall  in  blood-pressure,  transitory  in  nature.  The 
same  lowering  is  noted  when  the  peritoneum  is  incised 
and  also  when  viscera  are  pulled  upon  or  exposed  to 
the  drying  influence  of  air.  Two  procedures,  there- 
fore, to  be  studiously  avoided,  or,  if  necessary,  care- 


110  Surgical  Procedures. 

ful  watch  should  be  made  for  the  occurrence  of  shock, 
with  the  sphygmomanometer,  during  such  procedures. 
Cataract  Operation. — No  careful  surgeon  ever 
attempts  to  enter  an  eye  either  in  cases  of  glaucoma 
or  cataract  without  first  carefully  studying  the  blood- 
pressure.  The  indications  in  the  presence  of  a  high 
blood-pressure  are  first  to  reduce  the  pressure  and 
then  operate.  This  method  will  save  a  large  percen- 
tage of  eyes  which  were  formerly  lost  by  intraocular 
hemorrhage,  a  complication  the  direct  result  of  a  sud- 
den reduction  of  tension  in  an  eye,  having  diseased 
blood-vessels,  which  were  unable  to  withstand  the 
sudden  loss  of  support  following  the  scleral  incision. 


CHAPTER  VIIL 


THERAPEUTICS  INDICATED  BY  BLOOD-PRESSURE 
CHANGES 


Therapeutic  Indications 

Of  Hypotension 
Of  Hypertension 
With  Albuminuria 
In    Aortic   Aneurism 
In  Acute  Bright's  Disease 
Treatment  of  High  Pressures 
When  Not  to  Treat  It 
Effect  of   Nitrites     . 
Vapor  Baths 
Venesection 
Osteopathic   Measures 


111 

111 
111 
112 
112 
112 
112 
113 
113 
113 
113 
114 


Pilling;-Faug-ht  Pocket  Sphyg;momanometer  in  Use. 


CHAPTER  VIII 
THERAPEUTICS 

The  study  of  bloocl-i)rcssurc  frequently  furnishes 
the  key  to  proper  treatment  in  a  number  of  diseases ; 
it  also  furnishes  a  reliable  guide  as  to  the  efficiency  of 
the  measures  employed,  as  well  as  the  time  during 
which  treatment  should  be  continued. 

It  is  not  within  the  scope  of  this  little  work  to  more 
than  touch  upon  a  few  of  the  most  important  points 
in  the  relation  of  blood-pressure  to  the  management 
of  disease. 

Hypotension. — The  general  symptoms  accompanying 
diminished  blood-pressure  indicate  in  no  uncertain 
manner  the  necessity  of  tonic  treatment.  In  cases  of 
emergency,  w4th  suddenly  falling  pressure  and  evi- 
dence of  collapse,  adrenalin  intravenously  or  hypoder- 
mically  is  indicated. 

For  the  sudden  drop  in  blood-pressure  occurring  in 
advanced  arteriosclerosis,  digitalis  is  indicated,  pro- 
vided there  is  no  evidence  of  marked  myocardial 
degeneration,  in  which  event  strychnin  is  the  safer 
drug  to  use. 

In  lowered  blood-pressure  from  hemorrhage  or  pro- 
fuse and  prolonged  diarrhea,  the  pressure  is  the  best 
indicator  of  the  amount  and  the  frequency  for  the  use 
of  saline  infusion  or  the  Murphy  treatment. 

Hypertension.— High  pressure  in  the  apoplectically 
inclined  calls  for  active  and  continued  pressure-reduc- 
ing treatment.     Among  the  drugs  which  are  gener- 

111 


112  Treatment  of  High  Pressure. 

ally  depended  upon  to  accomplish  this  change  are  the 
nitrites,  of  which  a  freshly  prepared  solution  of 
Kodium  nitrite  will  be  found  the  most  serviceable,  being 
easy  of  administration  and  prolonged  in  action. 

In  the  treatment  of  aortic  aneurysm  with  high  pres- 
sure, the  use  of  blood-pressure  reducing  agents  may 
materially  prolong  life  by  reducing  the  tendency  to 
rupture,  and  at  the  same  time  afford  relief  from  the 
most  distressing  symptom — pain — by  lessening  the 
tension  in  the  aneurysmal  sac,  thereby  relieving  the 
nerve  irritation  and  the  pressure  upon  surrounding 
organs  or  tissues. 

In  acute  Bright's,  after  failing  to  reduce  the  pressure 
by  the  usual  measures,  it  may  sometimes  be  controlled 
by  the  electric-light  sweat  bath.  In  one  case  a  reduc- 
tion of  from  20  to  40  millimeters  was  obtained,  the 
beneficial  effects  lasting  for  many  hours,  so  that  regu- 
lar observation  of  the  pressure  determined  the  proper 
interval  between  the  sweats. 

Albuminuria. — Albumen  appears  in  the  urine  when- 
ever the  kidneys  are  passively  congested,  and  its 
importance,  when  due  to  this  cause,  is  often  greatly 
exaggerated.  Albuminuria,  associated  with  kidney 
disease,  is  nearly  always  accompanied  with  elevation 
in  blood-pressure ;  albumen,  when  due  to  other  causes, 
is  not  usually  so  accompanied.  As  these  two  causes 
of  albuminuria  demand  almost  diametrically  opposite 
treatment,  their  differentiation  is  of  the  utmost 
importance. 

When  to  Treat  High  Blood-pressure. — It  is  important 
to  realize  that  the  mere  finding  of  an  elevated  blood- 
pressure  is  not  always  an  indication  that  it  should  be 
reduced;  it  is  always  a  bad  rule  to  promiscuously 
institute  measures  to  reduce  pressure.     This  should 


Effect  of  DRUGh 


never  be  done.  Blood-pressure  reduction  should  only 
be  attempted  for  a  good  reason,  based  ui)on  a  careful 
study  of  the  case.  Long  continued  high  pressure  often 
becomes  an  essential  to  the  well-being  of  the  indi- 
vidual, which,  if  interfered  with,  may  so  destroy  the 
circulatory  equilibrium  that  disaster  results.  The 
chief  group  of  drugs  employed  to  control  and  lower 
high  blood-pressure  are  vasodilators.  These  act 
chiefly  upon  the  sympathetic  and  vasomotor  systems, 
cause  a  widening  of  the  blood  channels  and  a  conse- 
quent lowering  of  the  blood-pressure.  The  value  of 
the  sphygmomanometer  is  chiefly  in  demonstrating 
the  efficiency  of  the  measures  employed  in  any  given 
case.  This  guards  the  practitioner  from  placing  too 
much  confidence  in  any  particular  remedy,  because  he 
can  readily  ascertain  whether  he  is  accomplishing  the 
desired  result.  This  is  particularly  important  because 
numerous  investigators  have  shown  that  no  particular 
drug  can  be  depended  upon  to  produce  the  same 
results  under  all  conditions,  even  with  a  maximum 
dose.  Another  important  function  of  the  sphygmo- 
manometer in  therapeutics  is  to  determine  the  period 
of  duration  and  action  of  the  particular  drug  employed, 
thereby  enabling  the  physician  to  intelligently  manage 
his  therapeutic  measures  and  accomplish  his  purpose. 
The  sphygmomanometer  has  also  shown  that  many 
measures  other  than  drugs  may  be  relied  upon  to  con- 
trol and  lower  high  blood-pressure,  often  more  advan- 
tageously. Thus,  in  the  employment  of  vapor  baths 
of  various  sorts,  we  can  control  the  effect  and  deter- 
mine the  proper  time  for  another  treatment. 

In  venesection  the  amount  of  blood  which  may 
safely  be  withdrawn  is  best  determined  by  noting  the 
effect  of  the  bleeding  on  blood-pressure. 


114  Effect  of  Osteopathic  Treatment. 


Therapeutic  Effect  of   Osteopathic   Treatment 
ON  Blood-Pressure. 

J.  P.  Downing,  A.  B.,  D.  O.,  has  made  a  series  of 
studies  with  the  sphygmomanometer  over  a  period 
of  three  years  and  has  records  of  300  cases.  From 
the  result  of  this  study  it  is  apparent  that  the  meas- 
ures employed  were  productive  of  good  results  in 
certain  classes  of  high  tension  cases. 

This  seems  to  be  particularly  true  of  those  in  which 
there  is  no  physical  reason  for  the  hypertension  (many 
of  the  cases  were  studied  by  regular  practitioners  in 
order  to  exclude  organic  conditions  before  the  treat- 
ment was  applied).  Here  spinal  treatment  has  a 
decided  tendency  to  reduce  the  systolic  pressure,  the 
effects  of  which  are  usually  lasting,  often  persisting 
for  24  hours  or  more.  It  is  not  uncommon  to  get  a 
fall  of  from  15  to  40  mm.  after  a  treatment  occupying 
15  or  20  minutes.  These  results  are  confirmed  by 
Abrams  and  others,  who  are  at  the  present  time  em- 
ploying methods  somewhat  similar  to  those  of  oste- 
opathy, and  in  which  the  lower  cervical  region  is  the 
point  of  therapeutic  attack. 

It  is  evident  also  that  the  measures  applied  by 
osteopathy  are  productive  of  good  results  when 
applied  to  raising  an  abnormally  low  pressure.  In  16 
cases  of  anemia  reported,  the  pressure  ranged  from 
80  to  100,  which,  after  2^  months'  treatment,  with 
one  exception,  all  came  up  and  remained  above  110. 

In  6  cases  of  chlorosis,  in  which  the  blood-pressure 
averaged  90  before  treatment,  four  were  raised  to  120 
and  remained  up,  one  came  to  110,  and  only  one 
failed  to  respond  to  trieatment. 


CHAPTER  IX. 


BLOOD-PRESSURE  IN  LIFE  INSURANCE 


»rtance   of   the   Test 

115 

Normal   Variations    .... 

115 

Formula  to  Estimate  Normal  Pressure 

116 

Application  of  the  Test     . 

117 

In   Arteriosclerosis     . 

117 

In  Chronic    Nephritis 

117 

With    Albuminuria     . 

117 

In    Over- Weights 

118 

In  Chronic  Myocarditis     . 

118 

In     Tuberculosis 

118 

LIFE  INSURANCE 


The  medical  director  of  one  of  the  largest 

insurance  companies  speaking  of  the  Faught 

Pocket  Sphygmomanometer  writes  :    ''As 

you   know    we   have    used   the    Faught 

Sphygmomanometer  for  some  months, 

and  it  is   entirely  satisfactory  ;    it  is 

certainly     most      convenient. 


CHAPTER   IX 
BLOOD-PRESSURE   IN    LIFE   INSURANCE 

During  the  past  several  years  a  majority  of  life 
insurance  companies  have  admitted  the  value  of  the 
blood-pressure  test  as  a  prognostic  aid  in  life  insur- 
ance examinations.  At  the  present  time  most  of  the 
larger  companies  require  the  test  of  every  applicant 
for  life  insurance.  A  larger  number  require  the  test 
of  all  applicants  over  forty  years,  in  overweights  and 
underweights,  and  in  all  those  in  whom  the  character 
of  the  risk  has  been  previously  questioned  by  any 
company. 

The  chief  value  of  this  test  lies  in  the  fact  that,  by 
a  study  of  these  records  in  conjunction  with  that  of 
the  pulse,  we  are  able  to  detect  beginning  pathologic 
change  in  the  cardio-vascular  system  or  kidneys,  often 
before  there  are  any  definite  signs  in  the  physical 
examination,  personal  history  or  urine.  Another  good 
reason  for  the  universal  employment  of  the  blood- 
pressure  test  in  life  insurance  examinations  is  the  fact 
that  the  apparent  character  of  the  pulse  and  of  the 
vessel  walls  does  not  always  convey  the  correct  infor- 
mation regarding  the  condition  of  the  applicant.  Clini- 
cians have  agreed  that  the  estimation  of  blood-pres- 
sure by  palpation  is  not  satisfactory  and  that  even  the 
most  experienced  occasionally  fall  into  grave  error. 

Normal  or  Permissible  Variation. — Unlike  the  tempera- 
ture, which  has  a  fixed  normal,  the  blood-pressure  in 

115 


116  Blood-Pressure  in  Life  iNSxmANCE. 

the  normal  individual  is  a  variable  factor.  This  is 
because  of  the  complicated  cardiomotor  and  vasomotor 
mechanisms.  These  are  under  sympathetic  control, 
and  are  therefore  affected  by  the  varying  conditions  to 
which  the  body  is  subjected  during  every  24  hours. 
These  variations  result  from  changes  in  posture,  exer- 
cise, excitement  and  from  digestive  activity. 
They  are  also  dependent  upon  the  time  of  day,  age, 
sex  and  the  physical  development  of  the  individual. 
Fortunately  the  amount  of  alteration  in  pressure 
caused  by  these  varying  conditions  is  not  great,  and  we 
are  therefore  able  to  lay  down  a  fairly  definite  rule 
which  has  for  its  object  the  determination  of  the  per- 
missible variation  in  pressure  in  any  individual  of  a 
given  age. 

Formula  to  Estimate  Normal  Pressure. — The  writer 
devised  and  published,  in  1910,  a  formula  w^hich  may 
be  used  to  estimate  the  normial  systolic  blood-pressure, 
which  gives  results  conforming  closely  Avith  the  figures 
obtained  from  careful  clinical  reports.  The  formula 
is  as  follows:  "Consider  the  normal  average  systolic 
blood-pressure  in  men  at  age  of  20  to  be  120  mm. 
Then  add  1  mm.  for  every  additional  2  years  of  life." 
Thus  a  man  aged  30  should  have  a  normal  average 
systolic  blood-pressure  of  125  mm.,  while  a  man  aged 
60  should  average  140  mm.  The  difference  in  pres- 
sure between  men  and  women  is  approximately  10 
mm.,  being  lower  in  women. 

Clinical  evidence  shows  that  the  ordinary  daily 
variations  in  pressure  in  any  individual  rarely  amount 
to  more  than  36  mm.  If  we  accept  this,  then  a  varia- 
tion of  17,  either  above  or  below  the  normal  average, 
may  be  allowed. 


Appr.TrATrffX  or  Tf.st.  117 

Application  of  Test. — As  a  rouline  measure  the  left 
arm  should  be  employed  and  the  cuff  should  be  applied 
to  the  bare  arm.  The  applicant  should  be  in  a  com- 
fortable position,  preferably  sitting.  Time  should  be 
allowed  to  permit  the  circulation  to  become  quieted, 
and  nervous  individuals  should  bic  assured  of  the 
harmlessness  of  the  test. 

A  single  reading  equal  to  or  just  above  the  esti- 
mated maximum  pressure  for  a  given  individual 
should  never  be  accepted  as  final,  as  this  pressure  may 
be  accidental  and  may  never  again  be  met.  Observa- 
tions should  be  repeated  at  a  later  time  or  upon  a 
different  day  before  reporting  the  pressure. 

A  moderate  degree  of  arteriosclerosis  may  cause  an 
elevation  in  pressure  but  slightly  above  the  estimated 
high  normal;  15  or  20  mm.  above  this  calls  for  further 
investigation,  not  only  of  the  blood-pressure,  but  of 
the  general  physical  condition  of  the  applicant. 

The  blood-pressure  will  frequently  read  between 
160  and  180  mm.  in  the  average  case  of  uncompli- 
cated arteriosclerosis. 

Nephritis. — Urinalysis  does  not  always  demonstrate 
chronic  nephritis,  particularly  in  individuals  of  appar- 
ent normal  health.  On  the  other  hand,  it  is  said  that 
the  blood-pressure  in  an  established  case  of  chronic 
interstitial  nephritis  is  rarely  below  200  mm.  In  acute 
nephritis  the  blood-pressure,  while  above  the  normal, 
may  not  be  that  high.  The  finding  of  a  high  blood- 
pressure  with  a  normal  urine  calls  for  repeated 
urinalysis. 

Metabolic  Albuminuria. — The  finding  of  a  trace  of 
albumen  and  a  few  hyaline  casts  in  the  urine,  with  a 
normal  blood-pressure,   suggests  the  probability  that 


118  Conditions   Effecting   Pressure. 

the  urinary  condition  is  not  the  result  of  kidney  altera- 
tion, but  is  metabolic  in  character.  Such  a  condition 
can  readily  be  relieved  by  appropriate  treatment  while 
the  case  is  held  under  advisement,  and  many  of  them 
will  eventually  obtain  the  amount  of  insurance  desired. 

Overweights. — This  group  shows  an  unfavorable 
mortality  in  life  insurance  statistics,  particularly  of 
the  older  ages.  Given  an  individual  of  modern  over- 
weight, where  the  physical  examination  and  history 
are  favorable,  the  final  decision  is  often  made  upon 
the  result  of  the  blood-pressure  test;  accepting  them 
when  the  pressure  is  normal  and  declining  them  when 
the  pressure  reaches  or  passes  the  normal  high  limit. 

Chronic  Myocarditis. — This  is  the  most  difficult  con- 
dition to  diagnose,  especially  by  the  insurance  exami- 
ner, because  these  cases  often  require  long  study  and 
careful  observation  in  order  to  arrive  at  the  proper 
rating.  A  history  of  hard  physical  labor,  excessive 
brain  work,  alcoholism  or  syphilis  is  often  significant. 
In  the  early  cases  the  systolic  pressure  is  not  always 
altered,  so  that  recourse  must  be  had  to  the  functional 
tests  of  Graupner  and  Shapiro  (see  page  74),  and 
also  to  the  estimation  of  the  diastolic  and  pulse  pres- 
sures. 

Incipient  Tuberculosis. — Slight  reduction  in  blood- 
pressure,  combined  with  modern  elevation  in  pulse 
rate,  even  without  fever,  suggests  the  possibility  of 
an  active  pulmonary  lesion.  If  this  be  combined  with 
fever  and  a  history  of  slight  loss  in  weight,  the  case 
should  be  declined  on  this  presumptive  evidence.  In 
tuberculosis  the  blood-pressure  is  usually  low  and  the 
pulse  pressure  diminished. 


Blood- pRKss ukk  Stkt i i o.S(  oi'e. 


119 


PILLING-STAMP 
BRACELET  STETHOSCOPE 


IMPORTANCE  OF  ACCURACY  IN  BLOOD-PRESSURE 
EXAMINATIONS. 


Of  all  methods  of  recording  systolic  and  diastolic 
readings  there  is  not  one  dissenting  opinion  among 
scientists  that  the  auscultatory  is  the  one  absolutely 
correct  method.  Until  the  development  of  the  Stamp 
Bracelet  Stethoscope  the  labor  and  difficulty  surround- 
ing accurate  auscultatory  observations  in  blood-pressure 
were  almost  insurmountable  because  of  lack  of  prop- 
erly adjusted  and  sufficiently  delicate  apparatus. 


THE    METHODS    OF    TAKING    READINGS. 

There  are  probably  only   four  recognized  methods 
of  making  readings  and  they  are : 

1.  Visible. 

2.  Palpatory. 

3.  Auscultatory. 

4.  Diastolic  Indicators. 

Of  these  the  most  accurate   for  both  systolic  and 
diastolic  readings  is  the  auscultatory  method.     Prob- 


120  Auscultatory  Blood-Pressure. 

ably  there  is  a  slight  difference  between  diastolics  with 
this  method  and  the  other  three,  but  in  spite  of  this, 
it  is  the  most  satisfactory  in  every  way. 

It  is,  of  course,  for  purposes  of  comparison,  always 
•important  to  use  the  same  method  in  a  series  of  obser- 
vations, whether  on  individuals  or  groups. 

Accurate  records  of  the  blood-pressure  with  any 
sphygmomanometer  can  be  obtained  only  by  means  of 
the  auscultatory  method.  By  this  method  it  is  only 
necessary  to  distinguish  between  the  presence  and 
absence  of  certain  plainly  audible  sounds,  which  are 
not  affected  to  any  extent  by  varying  conditions,  such 
as  size  of  arm,  exact  location  of  vessel,  or  the  personal 
equation  of  the  examiner. 

All  large  Insurance  Companies  now  recognize  not 
only  the  importance  of  a  systolic,  but  also  of  a  diastolic 
determination. 

Ofttimes  we  find  that  a  relatively  high  systolic  is 
only  nature's  effort  to  compensate  and  that  there  is 
no  danger  from  it  whatever. 

This  observation  can  be  determined  only  by  the 
accurate  readings  made  possible  by  using  the  Stamp 
Bracelet. 

NORMAL   RELATION   OF   SYSTOLIC  TO   DIASTOLIC 
PRESSURE. 

There  exists  a  relationship  between  the  systolic  and 
diastolic  pressures  and  their  resultant  pulse  pressure 
that  has  been  generally  accepted  as  follows :  Where 
120-80-40  may  represent  the  systolic,  diastolic  and 
pulse  pressure,  respectively,  we  might  also  have  200- 
135-65  as  the  systolic,  diastolic  and  pulse  pressure, 
respectively,  and  still,  other  things  being  equal,  have 


Blood-Pkessure  Stethoscoim:.  IJl 

perfect  compensation,  relation  and  a  normal  balance 
between  the  various  parts  of  the  carflio-Nasnilar 
system. 

Before  this  accurate  method  of  diastolic  determina- 
tion was  devised,  moderately  elevated  pressures,  which 
had  had  only  the  systolic  determination,  would  not 
even  have  been  considered  by  the  Insurance  Com- 
panies, or  if  under  observation  by  a  physician,  the 
systolic  reading  alone  would  have  been  misleading. 

Dr.  Faught,  in  his  work  on  ''Blood-Pressure,"  says : 
"The  determination  of  the  pulse  pressure  is  of  the 
greatest  importance  in  the  study  of  diseased  condi- 
tions, particularly  in  the  estimate  of  cardiac  muscular 
efficiency  and  in  determining  the  prognosis  of  certain 
valvular  and  blood-vessel  diseases  and  toxemic  states." 

Dr.  J.  W.  Fisher,  Medical  Director  of  the  North- 
western Mutual  Life  Insurance  Company,  in  an  article, 
"The  Diagnostic  Value  of  the  Use  of  the  Sphygmoma- 
nometer in  Examinations  for  Life  Insurance,"  says : 

"No  practitioner  of  medicine  should  be  without  a 
sphygmomanometer.  He  has  in  this  instrument  a  most 
valuable  aid  in  diagnosis." 

Dr.  Haven  Emerson,  in  "Archives  of  Internal  Medi- 
cine," says:  "The  danger  of  accepting  applicants  who 
are  not  really  entitled  to  insurance  is  greatly  lessened 
by  the  determination  of  the  pulse  pressure,  and  no 
insurance  company  desires  to  refuse  a  policy  to  a  good 
risk,  and  in  no  way  can  this  be  positively  ascertained 
except  by  the  use  of  the  sphygmomanometer." 

Another  observer  says :  The  diastolic  readings  are 
more  important  than  the  systolic.  He  further  states 
that  the  auscultatory  method  of  obtaining  the  diastolic 
pressure  is  now  well  recognized  as  the  only  accurate 


122  Auscultatory  Blood-Pressure. 

and  simple  method,  because  if  you  observe  the  dial 
of  an  aneroid,  the  needle  is  showing  wide  excursions, 
making  it  impossible  to  determine  the  correct  reading, 
as  you  do  not  know  what  point  in  the  excursion  of 
the  needle  to  note. 

The  fluctuations  of  the  mercurial  column  offer  the 
same  difficulty. 

By  observing  the  changes  in  pulse  pressure  of  our 
cases  under  treatment,  we  obtain  the  most  accurate 
idea  possible  of  the  results  that  are  being  obtained; 
far  more  so  than  when  we  utilize  the  systolic  pressure 
alone. 

Now,  accepting  the  evidence  in  favor  of  the  import- 
ance of  accurate  diastolic  determinations  and  the  claim 
that  the  auscultatory  method  is  the  only  accurate  one, 
we  pass  to  the  choice  of  methods. 

Some  physicians  have  been  in  the  habit  of  tucking 
the  stethoscope  under  the  cuff.  It  is  obviously  impos- 
sible by  this  method  to  avoid  crepitus  and  annoyance 
and  interference  with  the  sounds  and  to  obtain  a  cor- 
rect reading,  for  the  instant  you  release  the  air  by  the 
various  methods  used  with  all  forms  of  sphygmoma- 
nometers the  cuff  must  yield  or  slip  over  the  stetho- 
scope, w4th  a  resulting  crepitus.  Manifestly,  to  hold 
the  stethoscope  in  place  manually  is  both  difficult  and 
inaccurate. 

The  Stamp  Bracelet  Stethoscope  may  be  used  with 
all  forms  of  sphygmomanometer  such  as  the  Faught 
Standard,  Faught  Pocket,  Cardiac,  Tycos,  Janeway, 
Stanton,  Riva  Rocci,    etc. 

In  employing  this  instrument,  attach  the  arm-band 
of  the  sphygmomanometer  to  the  arm  above  the  elbow 
in  the  usual  way,  then  the  Bracelet  is  quickly  and 
simply  adjusted  over  the  radial  artery  just  below  the 


Blood-Prkssuke  Stkthoscoi' 


123 


bifurcation.  The  especially  (lesij^nie(l  arterial  button 
fits  snugly  over  the  artery;  the  sounds  are  read  (|uickly 
with  unfailing  scientific  accuracy. 

Precision  is  now  assured ;  personal  errcjrs  (jn  the 
part  of  the  observer  are  eliminated  and  remarkably 
ready  and  general  acceptance  by  the  profession  at 
large  of  the 


G.P.PILLING  &  SON  CO.  PhlLK.  "^ 


Pilling-Stamp  Bracelet  Stethoscope 


is  proof  enough  of  its  high  degree  of  efficiency  in 
giving  to  the  practitioner  and  the  examiner  alike  an 
absolutely  accurate  method  of  making  determinations 
and  getting  satisfactory  interpretations  in  blood- 
pressure. 


16 
REASONS 

Why  The  Pilling -Faught 
Apparatus  is  Best 

1.  There  is  no  mechanical  detail  of  practical  value  in  any 
sphygmomanometer  which  is  not  embodied  in  those  of  the 
Faught-Pilling  make.     In  this  apparatus  you  will  find: 

2.  A  scale  running  to  300  mm.  Hg, 

3.  The  scale  graduated  in  milhmeters  requires  no  compu- 
tation to  determine  the  actual  pressure. 

4.  An  adjustable  dial  which  allows  for  changes  in  tem- 
perature and  atmospheric  pressure, 

5.  The  scale  plainly  marked  in  black  and  red  on  a  white 
background — easy  to  read. 

6.  The  aneroid  mechanism  has  four  chambers,  assuring 
absolute  smoothness  in  operation.  The  same  advantage  as  a 
"six"  auto  over  the  old  one  or  two  cylinder. 

7.  The  metal  pump  of  convenient  size  is  positively  guarded 
by  an  air-tight  valve. 

8.  A  reliable  release  valve  is  conveniently  placed  on  the 
shank  of  the  pump. 

9.  The  arm-band  is  standard  width  (5  inches)  and  of 
sufficient  length  to  meet  all  requirements. 

10.  The  pressure  bag  measures  9x5  inches. 

11.  The  outer  fabric  of  the  arm-band  is  of  washable  mate- 
rial and  permits  easy  sterilization. 

12.  Arrangement  for  quick  removal  of  the  pressure  bag 
from  the  outer  covering  for  cleaning  and  other  purposes. 

13.  An  attractive  leather  case  which_  holds  the  gauge,  arm- 
band and  pump,  and  is  of  convenient  size  to  fit  in  the  pocket. 

14.  Permanent  accuracy  which  has  been  demonstrated  by 
thousands  of  satisfied  users  working  under  all  conditions 
during  a  number  of  years. 

15.  The  Faught  Apparatus  is  in  general  use  by  thousands 
of  physicians,  by  the  U.  S.  Government,  many  life  insurance 
companies  and  research  laboratories,  as  the  standard  of 
accuracy. 

16.  Not  a  spring  instrument. 


Pilling-Faught 

Blood  Pressure  Service 

Generally  acknowledged  supremacy  is  not  the  work  of  a 
day  or  a  year,  but  the  cumulative  result  of  many  years' 
leadership  which  compels  gradual  recognition  and  emulation 
on  the  part  of  others  in  the  same  field. 

The  word  Service  is  the  key-note  of  Pilling  Success.  With 
us  it  signifies  much  more  than  the  term  usually  implies.  It 
means  service  from  us  to  the  surgical  dealer — from  the 
dealer  to  the  user — as  well  as  the  satisfactory  service  of 
every  Faught  Blood-Pressure  Apparatus  that  we  have  ever 
manufactured ;  the  service  that  will  insure  satisfactory 
results  at  all  times. 

In  order  to  afford  this  complete  service  we  have  built  up 
a  fully-equipped  organization,  comprised  of  accurate  tools 
and  the  best  mechanics ;  have  gathered  from  our  own  ex- 
perience as  well  as  that  of  others  the  most  advanced  ideas  in 
blood-pressure   apparatus    construction. 

Dr.  Francis  A.  Faught  is  in  daily  consultation  with  us, 
whose  duty  is  to  safeguard  the  sphygmomanometer  user  by 
maintaining  the  highest  standard  of  scientific  accuracy  which 
is  essential  in  such  an  instrument. 

The  unparalleled  demand  and  world-wide  market  for  the 
various  Faught  blood-pressure  instruments  have  made  it 
necessary  for  us  to  again  and  again  extend  our  organization; 
to  enlarge  our  manufacturing  facilities ;  and  broaden  the 
scope  of  both  our  manufactory  and  methods  of  distribution. 

Pilling  Service  starts  from  the  General  Manager's  desk 
and  continues  down  through  the  various  departments  to  your 
individual   consulting   room. 

Blood-pressure  apparatus  are  usually  guaranteed  perfect, 
but  a  Pilling  is  more  than  perfect — it  is  insured — for  it  is 
built  by  an  organization  whose  watchword  has  been  service. 

It  is  our  aim  and  ambition  to  maintain  and  augment  the 
high  standard  of  quality  that  has  always  been  found  in 
Faught-Pilling  instruments,  and  to  this  end  we  shall  continue 
to  strive  for  the  welfare  of  every  user  of  Faught  Instru- 
ments. 

A  copy  of  Faught' s  primer  as  2vell  as  a  signed  certificate 
is  furnished  with  every  apparatus. 

MADE  ONLY   BY 

G.  P.  PILLING  &  SON  CO. 

PHILADELPHIA,  PA. 


PILLING-FAUGHT 


Pocket 
Sphygmomanometer 


FAUGHT  POCKET 

ANEROID 

INSTRUMENT 

Complete  in  genuine  leather 
case,  with  Faught  Certificate 

$22.50  Net 


ACTUAL   SIZE 


MADE  ONLY  BY 

G.  P.  PILLING  &  SON  CO. 

PHILADELPHIA,  U.  S.  A. 


PILLING- FAUGHT 

Clinical 
Sphygmomanometer 


$27.50  Net 


Is  a  Portable  Pocket  Aneroid   Type  with 


DOUBLE  SIZE  DIAL  and 
REGISTERS  TO  350  Mm. 


OTHERWISE  SIMILAR    TO    REGULAR    FAUGHT    POCKET 


FAUGHT  MERCURY 

Sphygmomanometer 

ACCURATELY  STANDARDIZED 

SIMPLE,  COMPACT,  DURABLE,  EASY  TO  USE 

Always  ready  to  use ;  time  required  for  the  observation  reduced  to 
a  minimum ;  no  preliminary  adjustment  of  the  apparatus  required  ; 
mercury  cannot  be  spilled  ;  no  detachable  parts  to  be  lost. 


AN  INVALUABLE  AID  IN  DIAGNOSIS, 
PROGNOSIS  AND  TREATMENT 

Indespensable  to  the  General  Practitioner,  the  Internal  Specialist, 
the  Surgeon,  the  Oculist,  the  Laryngologist,  the  Otologist,  the 
Gynecologist,  the  Obstetrician  and  the  Student  of  Medicine. 

The  FAUGHT  SPHYGMOMANOMETER  embodies  the  essen- 
tials to  the  earlier  instruments  -while  omitting  unnecessary  complexity 
in  construction.  Thus  eliminating  the  objectionable  features  and 
reducing  to  a  minimum  the  time  required  for  observations. 

FOR  SALE  BY  ALL  SURGICAL  INSTRUMENT  DEALERS 

Complete.  Avith  Arm-band  and  Metal  Pump  in  Mahogany  Case, 
Avith  Signed  Certificate  of  Dr.  Faught. 


Price,  $20.00  Net 


PATENTED  AND  MADE  ONLY  BY 

G.  P.  PILLING  &  SON  CO, 

PHILADELPHIA,  U.  S.  A. 


PILLING  SPECIAL 

FAUGHT  PATENT 

Sphygmomanometer 

In  order  to  meet  the  demand  for  a  cheaper  model  of  the 
Faught  mercury  instrument,  the  PilHng  Special  has  been 
devised.  This  instrument  embodies  the  salient  features  of 
the  Faught  Standard  Sphygmomanometer,  and  will  be  found 
serviceable,  accurate  and  reliable. 


PILLING  SPECIAL  MADE  IN  TWO  GRADES 

No.  7— With  stiff  arm-band,  highly  finished  metal  parts 
and  with  mahogany  case,  3  x  3^  x  i^Yz  in.,  with  Faught 
Certificate,  $15.00  Net. 

No.  2— With  soft  arm-band  and  plain  oak  case,  3  x  zK 
X  14%  in.,  with  Faught  Certificate,  $12.00  Net. 


FOR  SALE  BY  ALL  SURGICAL  DEALERS 


PATENTED  AND  MADE  ONLY  BY 

G.  P.  PILLING  &  SON  CO. 

PHILADELPHIA,  U.  S.  A. 


PILLING -STAMP 

BRACELET 


G.P .PILLING  &SON  CO.  PHILK.  - 


FOR 


AUSCULTATORY 
BLOOD  PRESSURE 

Described  on  pa^es   119  to   123  this  Primer 


A  valuable  addition  to  every   make  of  Sphygrno- 
manometers.     May  be  used  on  any  style,  such  as 
Faught  Mercury  Janeway 

Faught  Pocket  Stanton 

Cardiac  Mercer 

Tycos  Riva-Rocci 

PRICE,  $5.00  NET 

MADE  ONLY  BY 

G.  P.  PILLING  &  SON  CO. 

PHILADELPHIA,  PA. 


THE   BOWLES  STETHOSCOPE 


PRICES 

Midget  I  in.  diam.     -----  $4.00  net 

Small  i^  in.  diam.    -----  4.00  net 

Medium  1%  in.  diam.        _         -         _         -  4.00  net 

Large  2/i  in.  diam.  -----  4.00  net 

Flat-iron  one  size  only       -         -         -         -  4.50  net 

Extra,  Combination  H.  R.  Bell          -         -  .50  net 

G.  P.  PILLING  &  SON  CO. 

SOLE    LICENSEES 
PHILADELPHIA,  U.  S.  A. 


SHERMAN 

VANADIUM  STEEL 

BONE  PLATES  ^  SCREWS 


/i^ 


Complete  set  of  i8  plates  as  shown  on  wood  panel 
$14.00 

Sing-le  Plates 

$1.00  EACH 

WITHOUT  SCREWS 

5/8  IN. 
1»^ 


Sherman  Screw   Driver,  $4.00  Net 
FOR  SALE   BY  ALL   SURGICAL    DEALERS 

G.  P.  PILLING  &  SON  CO. 

PHILADELPHIA,  PA. 


MERZON 

UMBILICAL 
CORD  TIE 

A  sealed  gflass  jar  contain- 
ing- twenty-five  yards  of  a 
smooth  silky  finish  cord  so 
braided  that  intense  strength 
is  secured  in  a  small  narrow 
braid. 

MERZON  Cord  being  fiat 
will  not  cut  or  injure  tissue. 

Merzon  Cord  is  so  placed 
in  the  packag^e  and  sealed 
that  just  the  amount  required 
for  each  operation  may  be 
withdraw^n,  without  soiling: 
contents  of  packag^e  and  the 
entire  contents  of  jar  used 
without  snarling-. 

Price,  TS  Cents 

MERZON  Umbilical  Cord  Tie  is  the  orig^inal 
and  only  safe  packag-e  to  handle.  Infring-ements  of 
Merzon  Cord  are  on  the  market  and  the  trade  is 
warned  ag-ainst  handling-  any  packag-e  other  than  the 
Merzon  Cord,  for  which  patents  are  applied  for. 

The  Convenience  and  Low  Cost  of  MERZON 
and  KORDO  have  made  them  favorites  among"  the 
physicians,  nurses,  undertakers  and  veterinarians. 
They  should  be  found  in  the  stock  of  every  surg'ical 
instrument  house  in  this  country. 


FOR  SALE  BY  ALL  SURGICAL  DEALERS 


HENRY  CLAYTON  &  BRO. 

Philadelphia,  Pa. 
SOLE   WHOLESALE   DISTRIBUTORS 


CAUTION 


Our  attention  has  been  called  by  physicians 
to  attempted 

SUBSTITUTION 

of  other  makes  of  Sphygmomanometers    by 

certain  retailers  because  of 

greater  profits. 

INSIST  ON   THE 

PILLING-FAUGHT 


G.  p.  PILLING  &  SON  CO. 

PHILADELPHIA,   PA. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

. 

C28(946)MIOO 

/ 
/ 

RC74 

Faught 


Fb7 

1914 

Copy  1 

Blood^ressure  priacr... 


C-/. 


^- 


I1U.BINDEEY 

\3\4- 


